School of Midwifery - Te Kura Atawhai Ka Kaiakapono Te Hakuitaka, Otago Polytechnic - Te Kura Matatini Ki Otago, Forth Street, Private Bag 1910, Dunedin 9054, New Zealand.
New Zealand.
Women Birth. 2018 Jun;31(3):232-239. doi: 10.1016/j.wombi.2017.09.012. Epub 2017 Sep 27.
Midwives have a professional, ethical and legal obligation to effectively and thoroughly document the care provided to women and the decisions made within the partnership relationship. To appreciate the best approach to documenting midwifery care, it is important to first understand the purpose of midwifery documentation.
The aim of this article is to explore the literature in relation to the purposes of midwifery documentation.
A literature search was performed using the CINAHL and Pubmed databases. Hand searching of reference and citation lists was employed to deepen the literature pool.
No research articles with a midwifery focus were found addressing the purpose of documentation. Broader searching of literature from other healthcare fields was drawn on to identify the contribution of record keeping to: partnership and continuity of care; communication between health professionals; improved standards of care; audits and clinical reviews; research and education; the visibility of midwifery work; the reflective practices of midwives; professional accountability; the legal record of care; the narrative record of experience for women.
The purpose of midwifery documentation is complex and multi-factorial, involving much more than the recording of clinical and legal details of a woman's care. Midwifery documentation may potentially enhance the maternity care experience for women, support the role of the midwife, positively impact collaboration between health professionals, and contribute to organisational processes and research. Further research is needed to clarify how to address the documentation priorities of women and midwives, within the context of the maternity record.
助产士有专业、道德和法律义务，要有效地、彻底地记录为妇女提供的护理以及在伙伴关系中做出的决策。为了了解记录助产护理的最佳方法，首先了解助产记录的目的很重要。
本文旨在探讨与助产记录目的相关的文献。
使用 CINAHL 和 Pubmed 数据库进行文献检索。通过手动搜索参考文献和引文列表，对文献库进行了深入研究。
没有发现以助产为重点的研究文章探讨记录的目的。从其他医疗保健领域更广泛地搜索文献，以确定记录保存对以下方面的贡献：伙伴关系和护理连续性；卫生专业人员之间的沟通；提高护理标准；审计和临床审查；研究和教育；助产工作的可见性；助产士的反思实践；专业问责制；护理的法律记录；妇女经历的叙述记录。
助产记录的目的是复杂的、多方面的，涉及的不仅仅是记录妇女护理的临床和法律细节。助产记录可能会增强妇女的分娩体验，支持助产士的角色，对卫生专业人员之间的合作产生积极影响，并有助于组织流程和研究。需要进一步研究如何在产妇记录的背景下解决妇女和助产士的记录优先事项。
