An investigation on the completeness of maternal records: record keeping practices of midwifery nursing care rendered to women in a district hospital in Namibia

Abstract

The importance of recording information in women’s records is to support the delivery of good care, clinical decision-making, communication between healthcare workers and continuity of care. It is assumed that good record keeping practices display the quality care rendered; hence the recording of actions by midwives provides evidence of the care they have rendered. A quantitative descriptive retrospective research was conducted to explore and describe the completeness of record keeping practices of the nursing care rendered by midwives during all stages of labour in a maternity ward of a district hospital in Namibia. Seventy-seven maternity records of women who delivered through normal vertex delivery from the 1st of January 2018 to the 31st of December 2018 were reviewed. Data collection was done using a structured checklist to determine adherence to record keeping legislation on completeness of maternity records. However, many areas of incompleteness of completeness in record keeping practices kept by midwives were identified.