助产士在林波波省医疗机构分娩期间记录护理的经验。
Midwives' experiences regarding recordkeeping during intrapartum care in Limpopo Province healthcare facilities.
机构信息
Department of Health Studies, School of Social Sciences, College of Human Sciences, University of South Africa, Pretoria.
出版信息
Curationis. 2024 Oct 25;47(1):e1-e7. doi: 10.4102/curationis.v47i1.2594.
BACKGROUND
South Africa has experienced an increase in litigations because of poor recordkeeping. The quality of maternal healthcare necessitates quality recordkeeping. All midwives' interventions should be documented in the maternity case record as an instrument to highlight the quality of intrapartum care offered.
OBJECTIVES
The purpose of the study was to determine and describe the experiences of midwives regarding recordkeeping during intrapartum care in Limpopo province and to make recommendations to improve recordkeeping.
METHOD
A qualitative, explorative and descriptive design was adopted. Midwives were selected purposively to participate in focus group discussions. Data were thematically analysed with the help of the independent transcriptionist and coder.
RESULTS
The findings revealed the themes: perceptions of midwives regarding recordkeeping and the challenges and enablers that influence recordkeeping during intrapartum care.
CONCLUSION
Quality recordkeeping requires timely, detailed, comprehensive and accurate recording. The study recommended the availability of updated guidelines, in-service training, monitoring and evaluation of recordkeeping, peer review, record auditing, proper time management among midwives and appointment of staff in line with the staffing needs of the unit to enhance recordkeeping.Contribution: Quality recordkeeping has a positive impact on the provision of quality healthcare to mothers during intrapartum care and reduces litigations related to maternity cases.
背景
由于记录保存不善，南非的诉讼案件有所增加。孕产妇保健的质量需要有高质量的记录保存。所有助产士的干预措施都应记录在产妇病历中，作为突出提供的产时护理质量的工具。
目的
本研究旨在确定并描述林波波省助产士在产时护理期间记录保存的经验，并提出改进记录保存的建议。
方法
采用定性、探索性和描述性设计。助产士被有目的地选择参加焦点小组讨论。在独立转录员和编码员的帮助下，对数据进行主题分析。
结果
研究结果揭示了以下主题：助产士对记录保存的看法，以及影响产时护理期间记录保存的挑战和促成因素。
结论
高质量的记录保存需要及时、详细、全面和准确的记录。研究建议提供最新的指南、在职培训、对记录保存的监测和评估、同行审查、记录审核、助产士的适当时间管理以及根据单位的人员配备需求任命工作人员，以加强记录保存。
贡献
高质量的记录保存对在产时护理期间为母亲提供优质医疗保健有积极影响，并减少与产妇病例相关的诉讼。
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