林波波省医疗机构助产士在产前护理记录方面的经验。

Phogole C Maesela, Johanna M Mathibe-Neke
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引用次数: 0

摘要

背景: 由于记录保存不善,南非的诉讼案件有所增加。孕产妇医疗保健的质量需要高质量的记录。助产士的所有干预措施都应记录在产科病例记录中,以此来突出产前护理的质量: 本研究旨在确定和描述林波波省助产士在产前护理记录方面的经验,并提出改进记录的建议: 方法:采用定性、探索和描述性设计。有目的地选择助产士参加焦点小组讨论。在独立记录员和编码员的帮助下,对数据进行了主题分析: 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前护理记录保存的挑战和促进因素: 结论:高质量的记录需要及时、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、同行评审、记录审计、助产士适当的时间管理以及根据单位的人员需求任命工作人员,以加强记录保存:高质量的记录保存对在产前护理期间为产妇提供高质量的医疗保健服务具有积极影响,并可减少与产妇案件有关的诉讼。
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Midwives' experiences regarding recordkeeping during intrapartum care in Limpopo Province healthcare facilities.

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.

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