- Email: [email protected]
Making midwifery work visible: The multiple purposes of documentation
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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Review article
Making midwifery work visible: The multiple purposes of documentation Bridget Kerkina,* , Susan Lennoxb , Jean Pattersonc a 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 b New Zealand c School of Midwifery — Te Kura Atawhai Ka Kaiakapono Te Hakuitaka, Otago Polytechnic — Te Kura Matatini Ki Otago, New Zealand
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 March 2017 Received in revised form 17 August 2017 Accepted 12 September 2017 Available online xxx
Background: 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. Aim: The aim of this article is to explore the literature in relation to the purposes of midwifery documentation. Method: 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. Findings and discussion: 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. Conclusion: 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. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Midwifery Purpose Documentation Record-keeping Notes
Contents 1. 2. 3. 4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Findings and discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Continuity of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Communication between health professionals . . . . . . . . . 4.3. Improving standards of care . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Audits and clinical reviews . . . . . . . . . . . . . . . . . . . . . . . . . 4.5. Data collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6. Contribution to the research environment and education 4.7. Makes midwifery work visible . . . . . . . . . . . . . . . . . . . . . . 4.8.
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* Corresponding author. E-mail address: [email protected] (B. Kerkin). https://doi.org/10.1016/j.wombi.2017.09.012 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
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5.
4.9. Reflection on practice and a record of experience for midwives . . . . . . . . . Professional expectation and demonstration of professional accountability 4.10. Legal record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.11. A narrative of experience for women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.12. Implications and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.13. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Statement of significance
Problem or issue Documentation is a key element of midwifery practice. What is already known There is a paucity of midwifery literature to guide midwifery record-keeping processes. What this paper adds Exploration of the comprehensive purposes of midwifery documentation and identification of the need for midwifery specific research to guide practice.
1. Introduction Midwives understand that pregnancy, birth, mothering and, by extension midwifery, have the potential to be powerfully transformative in the lives of women and their families.1 As a description of the maternity care experience, midwifery documentation is multi-dimensional and complex. Midwives have a professional, legal and ethical responsibility to thoroughly and accurately record the care provided to their clients, the information shared between woman and midwife and the decisions made within the midwifery partnership.2–4 However, it is clear that the documentation process can be challenging for midwives in practice.5,6 In order to identify how midwives can best achieve an effective clinical, legal and structural approach to this critical aspect of practice, it is necessary to first explore the purpose of midwifery record-keeping and to thoroughly understand why midwives ought to document to a high standard. This article offers a discussion of the multiple purposes of midwifery documentation. 2. Background There is an obligation for midwives to document a meaningful, useful, and thorough record for each and every midwifery contact and these documentation processes and requirements vary between countries and health jurisdictions. In Aotearoa/New Zealand, documentation practices are guided by both regulatory and professional bodies. For example, the Midwifery Council of New Zealand (MCNZ) determines professional and regulatory expectations for midwifery documentation, and the New Zealand College of Midwives (NZCOM) has developed standards, guidance and professional support for midwifery documentation. MCNZ Competencies One and Two of the ‘Competencies for Entry to the Register of Midwives’3 and NZCOM Standards of Practice three and four2 address the responsibility of the midwife to document comprehensive and informative clinical notes of their care, advice,
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discussions, and the plans and outcomes arising from these. Additionally, legislative frameworks for midwifery practice describe the requirement for midwives to record a comprehensive care plan for each woman7 and define how information must be collected, stored and accessed.8–10 Record-keeping is recognised as an area for improvement across many health professions11–14 and a lack of adequate documentation is cited in the majority of decisions arising from complaints against midwives in Aotearoa/New Zealand (http://www.hdc.org.nz/). Whilst responsibility for these deficits in practice generally falls to the individual practitioner, there is a paucity of evidence for what constitutes good documentation practice. This contributes to difficulty in the provision of professional guidance for midwives in this area. In order for midwives to understand how best to address the professional, legal and clinical aspects of record-keeping, they must first clearly understand the purpose of midwifery documentation. This understanding will inform the development of professional guidance which represents the interests of all relevant parties. Exploration of the objectives of the maternity record also affords each midwife an opportunity to develop professional understanding of the importance and relevance of documentation in their work, and how it contributes to the provision of excellent care to women and babies. 3. Method The intention was to undertake an extensive search of the literature relating to the purpose of midwifery documentation. To this end, the following search terms were entered into the CINAHL and Pubmed databases, with a specified time frame of 1990 to 2016: (midwif* AND (purpose* OR reason* OR intent* OR object*) AND (document* OR note* OR record*) NOT nurs*). Initially 271 entries from CINAHL and 370 entries from Pubmed were identified. These articles were evaluated on the basis of title, key words and the content of the abstract. From the initial search of 641 articles, just seven were found with a midwifery focus which referred to the topic of interest. 4,5,15–19 However, none discussed the topic in detail and none described research which specifically explored the purpose of midwifery documentation. These articles could not, therefore, form the basis of the identification of themes relating to midwifery documentation, and it became necessary to draw on literature from other healthcare fields. This was achieved via hand searching of the reference lists of the seven articles and citation lists of the databases. These articles and their respective reference lists increased the pool of literature available for further exploration (see Appendix A). Articles which incorporated discussion of the purpose of documentation, within the health profession of focus, were included in the broad pool of literature and the themes explored below were drawn from the selected literature.20 The articles were scrutinised and repetition of topics was identified. These topics were then sorted into categories21 and, where a minimum of three authors identified the importance of a category, the category was
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included, forming the basis of the identified themes. Literature of significance in the identification of these themes is summarised in Table A1 (Appendix B). For the development of this discussion, an assumption has been made that the purpose of documentation in other health professions is similar to that of midwifery. The literature has been applied as directly relevant to clinical record-keeping in midwifery practice, regardless of the professional context from which it was drawn. Whilst this approach is necessary for a thorough discussion about the purpose of documentation, it is important to maintain recognition of the differences between midwifery care and care in other health fields22 which might impact on record-keeping processes. The terms ‘documentation’, ‘record-keeping’, ‘notes’ and ‘record’ have been used in the respective literature and have thus been used interchangeably in the following discussion.
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enhances professional and client relationships, as well as the planning and provision of care.36,16,37 This will be relevant for midwives in any context, but may be particularly important for women and babies entering a multidisciplinary care environment where a variety of health professionals are likely to provide advice, information and treatment. The clear record of all clinical actions and considerations will assist the understanding of care providers,4,6,17 the woman’s decision-making, and the effective review of the well-being of mother and baby.15,38 Further, the thorough and careful recording of the woman’s understanding and experience, and the clinical progress of mother and baby will allow all health professionals to improve the standard of care proffered by tailoring their service to the individual needs of the woman and her infant.14,17,28,34 4.4. Improving standards of care
4. Findings and discussion 4.1. Partnership Partnership with women is the foundation of midwifery practice in Aotearoa/New Zealand2,22 and documentation may contribute to the effective development and maintenance of the woman-midwife partnership. As a shared record which the midwife and her client can co-create, midwifery documentation has the potential to promote communication between them.19,23,24 This record can, therefore, enhance shared understanding and contribute to decision-making within the partnership relationship.18,25 The collaborative development of the midwifery record clarifies expectations of all parties and demonstrates shared responsibility for choices and actions. It provides a platform for care planning and records the understanding of those who participate in the care of the mother and baby.26,27 This ensures that the knowledge of the woman, and the clinical expertise and understanding of best practice contributed by the midwife, will be clearly identified.25,28 The importance of the midwifery care record to the midwifery partnership remains relevant regardless of the context within which it is created. Midwifery documentation can contribute to the effectiveness of the continuity of care relationship between a community midwife and her client, just as it contributes to the continuity of the care provided to a woman by different caregivers.23,29 4.2. Continuity of care Midwifery documentation provides a record of experience (contemporaneous and retrospective) for both the woman and the midwife, details the sequence of events, and clearly communicates the woman’s care plan.13,29,30 For example, the maternity notes developed by midwives monitor the progress of the person receiving the care and record the woman’s and baby’s response to physiological changes, and any treatments and interventions undertaken. Therefore, the current clinical circumstances of the mother and baby, and the woman’s understanding and experience of these, can be recorded.30,31 Where necessary, this record supports a more seamless sharing of care and transition between health professionals5,26,32,33 as the midwifery record contributes evidence of the care provided and decisions made,29,31 allowing communication of the midwife’s actions and the woman’s needs, plans, priorities and consent, to other care providers.11,34,35 4.3. Communication between health professionals When health professionals develop and use clear, contemporaneous records, these provide a platform for communication that
Clear documentation of the care plan, and the needs and priorities of the woman for herself and her baby, along with the record of the unfolding clinical scenario, will contribute to the experience and safety of mother and infant.39 When care priorities are clearly visible to all providers, and the woman and her family, there is reduced potential for clinical error, misunderstanding and miscommunication.16,27,30 In this way, appropriate documentation represents one aspect of the protection of health consumer rights.40 Record-keeping has implications, therefore, for the individual woman and her baby, and also for local communities and the healthcare institutions which serve them. The understanding afforded by the midwifery notes can contribute to exploration of the care provided; what went well and what might be improved.41 This is true both in the immediate clinical circumstance, for the later reflective understanding of events by the individuals involved,42 and from the perspective of professional review processes.43,44 4.5. Audits and clinical reviews Effective record-keeping contributes to accurate auditing processes and clinical reviews11,16 and facilitates exploration of the provision of care at individual, departmental, hospital and national levels.27,45 Audit processes allow for consideration of the effectiveness of the service and identification of priority areas for further exploration.29 Likewise, reviews of critical clinical incidents support the development of the service, and demonstrate accountability and the transparency of service provision.41 These processes contribute to the understanding of all parties, when events are explored with a focus on the improvement in the systems of care.40 Clinical documentation forms the basis for exploring and understanding events as they unfolded.27,46
4.6. Data collection Meaningful interpretation of maternity outcomes, specific aspects of care provided and the exploration of service provision relies on accurate collection of qualitative and quantitative information.35,41 As a result of this need for clear data to support and evaluate the quality and safety of care, hospitals, professions and government departments have clear minimum requirements for data collection. Midwifery documentation informs the collection of midwifery statistics, hospital statistics and national statistics.27 This information has the potential to improve the quality and safety of services provided by hospitals and the maternity system.47–49 Additionally, these data can be used to support the development of
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the midwifery body of knowledge, through research and education processes.29,45,50 4.7. Contribution to the research environment and education Midwifery notes provide evidence which informs the purposes of research29 and also a platform to explore “best” practice.16,41 The maternity record establishes evidence of midwifery knowledge and relationships, and provides an opportunity to articulate the priorities of women and midwives. The record then can be used for educational purposes and for research. By thoroughly and accurately documenting the detail of their work, midwives can influence and guide the knowledge of current and aspiring members of the profession,46 contributing to the experience and development of student midwives27,40,45 and informing the understanding of other interested parties.38,51 The importance of the accuracy of the maternity record is accepted, as the ability of researchers to interpret the care provided, the sequence of events which have occurred and the outcomes of the recipients of care, is determined largely by the content of the record.29,41 4.8. Makes midwifery work visible As a result of the contribution to clinical, institutional, national and academic environments, midwifery record-keeping has the potential to improve the visibility of the work of midwives.51,52 For this reason, it is important that documentation is detailed enough to provide evidence of the thoroughness of the care provided. A detailed record articulates the role that the midwife fulfills for the woman and her family, and conveys the expert knowledge and skills of the midwife.29,52,53 What is documented becomes visible to many parties, including those responsible for the funding and planning of maternity services.16,54 This has potential to improve resources available to women, babies and midwives29,33,48,49 and may impact the development of policy relevant to midwifery practice.50,55 A related consideration is the potential for a written record of midwifery care, which is based upon the shared language of women and midwives, to communicate the nature of midwifery work.51,52 Carefully developed midwifery notes can serve to identify and emphasise the many ways in which midwifery care is both related to, and differs from, obstetric care.27 Midwifery documentation records the breadth of midwifery care and, in this way, helps to define and frame midwifery practice. The complexity, depth and holistic nature of midwifery can be articulated in the clinical record,34,38 serving to clarify the unique and personal characteristics of the midwife-woman relationship.27,56 This concept is captured by Miller and Wilkes:25 Documentation which is an artful blend of both the objective findings and the social/emotional context may articulate additional dimensions of midwifery knowledge as effectively as empirical knowledge derived from research, and deserves to be as highly valued by health professionals as it is by women (p. 416).
4.9. Reflection on practice and a record of experience for midwives As documentation makes midwifery work more visible to institutions, policy makers and the public, so it can also make this work more visible to the individual midwife, facilitating reflection on practice.57 In the process of recording the clinical notes the midwife is able to reflect on the potential courses of action available for the woman and/or baby and to consider the most appropriate care plan. The care provider may, therefore, understand the experience, circumstances and clinical condition of the
person receiving the care, and this provides opportunity for more effective individualisation of services.14,28,34 For example, in a continuity of care relationship the midwifery record will help the midwife remember previous conversations and decisions relevant to the care of her client.46 This will enhance the partnership relationship and improve care planning.25 As a retrospective tool, midwifery documentation allows the midwife to look back on her work and explore her communications, the decisions made with the woman, actions taken and plans developed.29 She can evaluate her responses and consider the ways in which the experience and outcomes of her clients may have been affected.14 The maternity notes are, therefore, a record of experience for the midwife, of her practice, her relationship with the woman and other parties, and can afford her a particular insight into her own professional development.27 4.10. Professional expectation and demonstration of professional accountability The midwifery record demonstrates the midwife’s accountability but also supports her ability to be accountable. In Aotearoa/ New Zealand, the regulatory and professional organisations for midwifery practice clearly identify the requirement for midwives to write a meaningful record for each and every midwifery encounter.2,3 Documentation allows the midwife to measure her practice against quality and professional standards.27 Thorough documentation demonstrates the midwife’s responsibility for her work.36,58 It supports her to meet professional requirements such as recertification processes.59 The visibility of midwifery care, within midwifery record-keeping, enhances the accountability of individual midwives30,51 and the transparency of the maternity service.41,60 Meeting these professional expectations for documentation, and thoroughly recording the care provided to women, allows the midwife and others to demonstrate whether the midwife has behaved in a manner considered reasonable by her peers.34,58,61 4.11. Legal record The maternity record for a woman and baby constitutes a legal reference in circumstances which necessitate a review of the care provided, or of the outcome, for the mother and/or the infant.29 Thorough documentation provides a summary of events which have occurred and details of the care provided.18,30 It therefore demonstrates, step by step, the critical analysis made by the midwife, her awareness of the developing clinical circumstance and whether the actions taken were appropriate.34,51 The midwife’s understanding of requirements for the structural aspects of the record is informed by the legal frameworks available within the midwife’s practice context, and these support midwives to meet their professional record-keeping accountabilities.7–10 A number of authors have provided clear discussion of the legal and structural considerations for record-keeping and these aspects are frequently explored in international literature on the topic of documentation.31,36,54,62–64 The extent to which health professionals should focus on the use of healthcare records for legal purposes is also debated within the literature.58,65 There is no doubt that midwifery documentation is a valuable resource for clinical review and audit processes. However, many authors contend that the value of health records extends well beyond legal and regulatory parameters.34,55,56 4.12. A narrative of experience for women Midwifery documentation has the potential to enhance the experience of women accessing maternity care.5,24 A woman’s
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midwifery notes will serve to clarify her understanding of events and record significant aspects of her experience, as well as her priorities for care.15,66 The maternity record supports her current understanding of her care and care arrangements, and documents her maternity journey in a way which she can reflect on, in the future.67 The documentation of explanations and information provided for women in woman-held notes will enhance the autonomy of the mother and her family.16,23,68,69 When a woman can refer to a clinical record which is developed specifically for her circumstance and consideration, she has increased opportunity to take responsibility for her own wellbeing and that of her baby.5,15,24,70,71 Midwifery documentation has the potential, therefore, to improve the participation of women in their care.15,16,72 The midwifery record may contribute to, and represent, a woman’s experience of her maternity care in a way which articulates more than clinical events. The priorities and preferences of pregnant, birthing and postnatal women may be made more visible to all parties, enhancing the quality and safety of maternity care.25,66 4.13. Implications and recommendations There are identified professional and legal parameters for midwifery record-keeping. However, the midwifery profession will benefit from further understanding of documentation, including the priorities for the maternity record defined by women, midwives, allied professions and relevant professional and regulatory bodies. Further research is needed to clarify these priorities and to develop clear guidance for midwives as to how they might satisfy all aspects within the woman’s maternity record.
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each woman and baby. Thorough and accurate record-keeping explains the care planned by, and for, the woman and details the actions of the midwife. Documentation contributes to the demonstration of midwifery accountability and articulates the work undertaken by midwives. It enhances the collection of relevant and accurate statistics at individual, hospital and national levels and contributes to the research environment. Midwifery records have the potential to improve our understanding of the maternity needs of women, their families and the community, whilst clarifying the professional contribution of the midwife. These clinical notes constitute a legal record which demonstrates the midwife’s practice and development, and may support audit and clinical review processes. This multi-dimensional component of midwifery care can enhance the relationships of, and collaboration between, care providers and contribute to service provision at a broader level. The development of a meaningful record supports continuity of care for women and seamless sharing of care between different health professionals. Midwifery documentation records details of the relationship between a woman and her midwife and the decisions they make together. The maternity care record can enhance the experience of both women and midwives, by communicating the priorities of women and articulating the midwife’s practice and expertise. Acknowledging these diverse purposes of the documentation of midwifery care, further research can contribute an understanding of how we might meet these purposes within the context of the woman’s maternity record.
Funding No external financial support was received for the publication of this article.
5. Conclusion Acknowledgments Midwifery documentation, as the record of the maternity care journey of women and babies, is a critical component of the work of midwives. It has an essential role in the safe provision of care to
I would like to acknowledge Otago Polytechnic for support in the preparation of this publication.
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Appendix A Fig. A1.
Fig. A1. One PRISMA diagram of literature searching process.
Appendix B Table A1. Table A1 One literature summary table. Authors
Title
Description
Andrews and St Aubyn36
‘If it’s not written down; it didn’t happen . . . ’
Discussion of the importance of timely, accurate and Authors summarise the impact of good thorough record-keeping documentation processes and highlight the potential impact of poor record-keeping. They identify that the documentation of interactions between nurses and patients is important.
Baskaran et al.16
Managing information and knowledge within maternity services: Privacy and consent issues
A “mixed-mode methodology of literature reviews, structured questionnaires and semi-structured interviews” (p198)
Summary
The data available from clinical records can support the provision of maternity services and improve health outcomes. It can also inform funding and planning, research and policy development.
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Table A1 (Continued) Authors
Title
Description
Summary The authors address the security of electronic health records.
Blair and Smith30
Nursing documentation: Framework and barriers
Literature search using CINAHL and MEDLINE
Nurses continue to struggle to find the time and effective strategies to document adequately in practice. There are many barriers to acceptable nursing documentation. Frameworks for documentation may help streamline record-keeping processes.
Buus and Hamilton51
Social science and linguistic text analysis of nurses' records: A systematic review and critique
Systematic searching undertaken in databases and citation indexes
The use of language which is highly technical, abbreviated, and often not generic, may undermine the experience of the reader. The practise of nursing is often not visible in nursing records which are heavily medically dominated.
Cheevakasemsook et al.45
The study of nursing documentation complexities
Multiple methods of exploration were used:
Six themes were identified to summarise the complexities of nursing documentation: Interviewing, participant observation, nominal group Disruption of documentation processing, focus groups, nursing record audits and Incompleteness in charting time and motion study of nursing care Inappropriate charting Limited nurses competence, motivation and confidence Ineffective nursing procedures Inadequate nursing auditing, supervision and staff development
Irving et al.38
Discursive practices in the documentation of patient assessments
Foucauldian analysis of 45 patient records
Jefferies et al.34
A meta-study of the essentials of quality nursing documentation
A synthesis of literature about nursing documentation 7 themes identified the “essentials of quality nursing documentation”: Theme 1: Nursing documentation should be patient centred Theme 2: Nursing documentation must contain the actual work of nurses including education and psychosocial support Theme 3: Nursing documentation is written to reflect the objective clinical judgement of the nurse Theme 4: Nursing documentation must be presented in a logical and sequential manner Theme 5: Nursing documentation should be written as events occur Theme 6: Nursing documentation should record variances in care Theme 7: Nursing documentation should fulfil legal requirements
Kelley et al.28
Electronic Nursing Documentation Integrative review of the literature exploring the as a Strategy to Improve Quality of relationship between electronic nursing Patient Care documentation and patient care
Zegers et al.41
Quality of patient record keeping: Retrospective review of patient records from 21 Dutch Poor record quality seemed to be associated with an indicator of the quality of care? hospitals. poorer outcomes for patients. Additionally, reduced quality of record-keeping impacted the ability of the reader to review the notes and accurately identify outcomes.
Three identifiable discursive practices were discerned to be used by nurses in their records: Medical Nursing Informal The authors conclude that these nursing documentation practices identify and contribute to the definition of nurses and the nursing profession.
Discussion of the importance of documentation for supporting the critical reflection, analysis and care planning of nurses. Nurses opinions about, and perceptions of, electronic documentation are well represented in the literature. However, the impact of electronic nursing documentation on patient safety and outcomes remains unclear.
Articles which formed the most significant basis of the discussion are included here.
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Homer C, Catling-Paull, Sinclair D, Faizah N, Balasubramanian V, Foureur M. Developing an interactive electronic maternity record. Br J Midwifery 2010;18:384–9. 27. Tharpe NL, Farley CL, Jordan RG. Clinical practice guidelines for midwifery & women’s health. 5th ed. Burlington, MA: Jones and Bartlett Publishing; 2016. 28. Kelley TF, Brandon DH, Docherty SL. Electronic nursing documentation as a strategy to improve quality of patient care. J Nurs Scholarsh 2011;43:154–62. 29. Adams C. A documentation standard for the maternal and child health nurse in Victoria. 2015 http://www.anmfvic.asn.au/news-and-publications/news/ 2015/01/08/victorian-maternal-and-child-health-service-documentationstandards. 30. Blair W, Smith B. Nursing documentation: framework and barriers. Contemp Nurse 2012;41:160–8. 31. Griffith R. Records: what to include. Br J Midwifery 2016;24:743–4. 32. Björvel C, Wredling R, Thorell-Ekstrand I. Improving documentation using a nursing model. J Adv Nurs 2003;43:402–10. 33. 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34. Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. Int J Nurs Pract 2010;16:112–24. 35. Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. J Adv Nurs 2011;67 (9):1858–75. doi:http://dx.doi.org/10.1111/j.1365-2648.2011.05634.x. 36. Andrews A, St Aubyn B. ‘If it’s not written down; it didn’t happen . . . ’. J Community Nurs 2015;29:20–2. 37. Instefjord MH, Aasekjær K, Espehaug B, Graverholt B. Assessment of quality in psychiatric nursing documentation—a clinical audit. BMC Nurs 201413(32). doi:http://dx.doi.org/10.1186/1472-6955-13-32. 38. Irving K, Treacy M, Scott A, Hyde A, Butler M, MacNeela P. Discursive practices in the documentation of patient assessments. J Adv Nurs 2006;53:151–9. 39. Dimond B. Legal aspects of midwifery. London: Quay Books; 2013. 40. Jefferies D, Johnson M, Nicholls D. Comparing written and oral approaches to clinical reporting in nursing. Contemp Nurse 2012;42:129–38. 41. Zegers M, de Bruijne MC, Spreeuwenberg P, Wagner C, Groenewegen PP, van der Wal G. Quality of patient record keeping: an indicator of the quality of care? Qual Saf Health Care 2011;20:314–8. doi:http://dx.doi.org/10.1136/ bmjqs.2009.038976. 42. Thorpe J, Anderson J. Supporting women in labour and birth. In: Pairman S, Pincombe J, Thorogood C, Tracy S, editors. Chatswood, NSW: Churchill Livingstone; 2015. p. 626–55. 43. De Marinis MG, Piredda M, Pascarella MC, Vincenzi B, Spiga F, Tartaglini D, et al. ‘If it is not recorded, it has not been done!’? Consistency between nursing records and observed nursing care in an Italian hospital. J Clin Nurs 2010;19:1544–52. 44. Wright K. Ensuring best practice in clinical record keeping. Nurs Times 2013;109:20–1. 45. Cheevakasemsook A, Chapman Y, Francis K, Davies C. The study of nursing documentation complexities. 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An exploration of the factors that affect nurses’ record keeping. Br J Nurs 2003;12:751. 54. Doncliff B. Improving the quality of nursing notes. Kai Tiaki Nurs New Zeal 2015;21:27–9. 55. Butler M, Treacy M, Scott A, Hyde A, Mac Neela P, Irving K, et al. Towards a nursing minimum data set for Ireland: making Irish nursing visible. J Adv Nurs 2006;55:364–75. 56. Davis MP, Payne S. Nursing care, documentation and discourse. Prog Palliat Care 2009;17:109–10. 57. Heartfield M. Nursing documentation and nursing practice: a discourse analysis. J Adv Nurs 1996;24:98–103. 58. Prideaux A. Issues in nursing documentation. Br J Nurs 2011;20:1450–5. 59. New Zealand College of Midwives. Regulation. https://www.midwife.org.nz/ in-new-zealand/regulation. 60. Lees L. Improving the quality of nursing documentation on an acute medicine unit. Nurs Times 2010;106:22–6. 61. Owen K. Documentation in nursing practice. Nurs Stand 2005;19:48–9. 62. Forrester K. 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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Review article
Making midwifery work visible: The multiple purposes of documentation Bridget Kerkina,* , Susan Lennoxb , Jean Pattersonc a 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 b New Zealand c School of Midwifery — Te Kura Atawhai Ka Kaiakapono Te Hakuitaka, Otago Polytechnic — Te Kura Matatini Ki Otago, New Zealand
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 March 2017 Received in revised form 17 August 2017 Accepted 12 September 2017 Available online xxx
Background: 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. Aim: The aim of this article is to explore the literature in relation to the purposes of midwifery documentation. Method: 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. Findings and discussion: 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. Conclusion: 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. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Midwifery Purpose Documentation Record-keeping Notes
Contents 1. 2. 3. 4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Findings and discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Continuity of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Communication between health professionals . . . . . . . . . 4.3. Improving standards of care . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Audits and clinical reviews . . . . . . . . . . . . . . . . . . . . . . . . . 4.5. Data collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6. Contribution to the research environment and education 4.7. Makes midwifery work visible . . . . . . . . . . . . . . . . . . . . . . 4.8.
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* Corresponding author. E-mail address: [email protected] (B. Kerkin). https://doi.org/10.1016/j.wombi.2017.09.012 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
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4.9. Reflection on practice and a record of experience for midwives . . . . . . . . . Professional expectation and demonstration of professional accountability 4.10. Legal record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.11. A narrative of experience for women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.12. Implications and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.13. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Statement of significance
Problem or issue Documentation is a key element of midwifery practice. What is already known There is a paucity of midwifery literature to guide midwifery record-keeping processes. What this paper adds Exploration of the comprehensive purposes of midwifery documentation and identification of the need for midwifery specific research to guide practice.
1. Introduction Midwives understand that pregnancy, birth, mothering and, by extension midwifery, have the potential to be powerfully transformative in the lives of women and their families.1 As a description of the maternity care experience, midwifery documentation is multi-dimensional and complex. Midwives have a professional, legal and ethical responsibility to thoroughly and accurately record the care provided to their clients, the information shared between woman and midwife and the decisions made within the midwifery partnership.2–4 However, it is clear that the documentation process can be challenging for midwives in practice.5,6 In order to identify how midwives can best achieve an effective clinical, legal and structural approach to this critical aspect of practice, it is necessary to first explore the purpose of midwifery record-keeping and to thoroughly understand why midwives ought to document to a high standard. This article offers a discussion of the multiple purposes of midwifery documentation. 2. Background There is an obligation for midwives to document a meaningful, useful, and thorough record for each and every midwifery contact and these documentation processes and requirements vary between countries and health jurisdictions. In Aotearoa/New Zealand, documentation practices are guided by both regulatory and professional bodies. For example, the Midwifery Council of New Zealand (MCNZ) determines professional and regulatory expectations for midwifery documentation, and the New Zealand College of Midwives (NZCOM) has developed standards, guidance and professional support for midwifery documentation. MCNZ Competencies One and Two of the ‘Competencies for Entry to the Register of Midwives’3 and NZCOM Standards of Practice three and four2 address the responsibility of the midwife to document comprehensive and informative clinical notes of their care, advice,
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discussions, and the plans and outcomes arising from these. Additionally, legislative frameworks for midwifery practice describe the requirement for midwives to record a comprehensive care plan for each woman7 and define how information must be collected, stored and accessed.8–10 Record-keeping is recognised as an area for improvement across many health professions11–14 and a lack of adequate documentation is cited in the majority of decisions arising from complaints against midwives in Aotearoa/New Zealand (http://www.hdc.org.nz/). Whilst responsibility for these deficits in practice generally falls to the individual practitioner, there is a paucity of evidence for what constitutes good documentation practice. This contributes to difficulty in the provision of professional guidance for midwives in this area. In order for midwives to understand how best to address the professional, legal and clinical aspects of record-keeping, they must first clearly understand the purpose of midwifery documentation. This understanding will inform the development of professional guidance which represents the interests of all relevant parties. Exploration of the objectives of the maternity record also affords each midwife an opportunity to develop professional understanding of the importance and relevance of documentation in their work, and how it contributes to the provision of excellent care to women and babies. 3. Method The intention was to undertake an extensive search of the literature relating to the purpose of midwifery documentation. To this end, the following search terms were entered into the CINAHL and Pubmed databases, with a specified time frame of 1990 to 2016: (midwif* AND (purpose* OR reason* OR intent* OR object*) AND (document* OR note* OR record*) NOT nurs*). Initially 271 entries from CINAHL and 370 entries from Pubmed were identified. These articles were evaluated on the basis of title, key words and the content of the abstract. From the initial search of 641 articles, just seven were found with a midwifery focus which referred to the topic of interest. 4,5,15–19 However, none discussed the topic in detail and none described research which specifically explored the purpose of midwifery documentation. These articles could not, therefore, form the basis of the identification of themes relating to midwifery documentation, and it became necessary to draw on literature from other healthcare fields. This was achieved via hand searching of the reference lists of the seven articles and citation lists of the databases. These articles and their respective reference lists increased the pool of literature available for further exploration (see Appendix A). Articles which incorporated discussion of the purpose of documentation, within the health profession of focus, were included in the broad pool of literature and the themes explored below were drawn from the selected literature.20 The articles were scrutinised and repetition of topics was identified. These topics were then sorted into categories21 and, where a minimum of three authors identified the importance of a category, the category was
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included, forming the basis of the identified themes. Literature of significance in the identification of these themes is summarised in Table A1 (Appendix B). For the development of this discussion, an assumption has been made that the purpose of documentation in other health professions is similar to that of midwifery. The literature has been applied as directly relevant to clinical record-keeping in midwifery practice, regardless of the professional context from which it was drawn. Whilst this approach is necessary for a thorough discussion about the purpose of documentation, it is important to maintain recognition of the differences between midwifery care and care in other health fields22 which might impact on record-keeping processes. The terms ‘documentation’, ‘record-keeping’, ‘notes’ and ‘record’ have been used in the respective literature and have thus been used interchangeably in the following discussion.
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enhances professional and client relationships, as well as the planning and provision of care.36,16,37 This will be relevant for midwives in any context, but may be particularly important for women and babies entering a multidisciplinary care environment where a variety of health professionals are likely to provide advice, information and treatment. The clear record of all clinical actions and considerations will assist the understanding of care providers,4,6,17 the woman’s decision-making, and the effective review of the well-being of mother and baby.15,38 Further, the thorough and careful recording of the woman’s understanding and experience, and the clinical progress of mother and baby will allow all health professionals to improve the standard of care proffered by tailoring their service to the individual needs of the woman and her infant.14,17,28,34 4.4. Improving standards of care
4. Findings and discussion 4.1. Partnership Partnership with women is the foundation of midwifery practice in Aotearoa/New Zealand2,22 and documentation may contribute to the effective development and maintenance of the woman-midwife partnership. As a shared record which the midwife and her client can co-create, midwifery documentation has the potential to promote communication between them.19,23,24 This record can, therefore, enhance shared understanding and contribute to decision-making within the partnership relationship.18,25 The collaborative development of the midwifery record clarifies expectations of all parties and demonstrates shared responsibility for choices and actions. It provides a platform for care planning and records the understanding of those who participate in the care of the mother and baby.26,27 This ensures that the knowledge of the woman, and the clinical expertise and understanding of best practice contributed by the midwife, will be clearly identified.25,28 The importance of the midwifery care record to the midwifery partnership remains relevant regardless of the context within which it is created. Midwifery documentation can contribute to the effectiveness of the continuity of care relationship between a community midwife and her client, just as it contributes to the continuity of the care provided to a woman by different caregivers.23,29 4.2. Continuity of care Midwifery documentation provides a record of experience (contemporaneous and retrospective) for both the woman and the midwife, details the sequence of events, and clearly communicates the woman’s care plan.13,29,30 For example, the maternity notes developed by midwives monitor the progress of the person receiving the care and record the woman’s and baby’s response to physiological changes, and any treatments and interventions undertaken. Therefore, the current clinical circumstances of the mother and baby, and the woman’s understanding and experience of these, can be recorded.30,31 Where necessary, this record supports a more seamless sharing of care and transition between health professionals5,26,32,33 as the midwifery record contributes evidence of the care provided and decisions made,29,31 allowing communication of the midwife’s actions and the woman’s needs, plans, priorities and consent, to other care providers.11,34,35 4.3. Communication between health professionals When health professionals develop and use clear, contemporaneous records, these provide a platform for communication that
Clear documentation of the care plan, and the needs and priorities of the woman for herself and her baby, along with the record of the unfolding clinical scenario, will contribute to the experience and safety of mother and infant.39 When care priorities are clearly visible to all providers, and the woman and her family, there is reduced potential for clinical error, misunderstanding and miscommunication.16,27,30 In this way, appropriate documentation represents one aspect of the protection of health consumer rights.40 Record-keeping has implications, therefore, for the individual woman and her baby, and also for local communities and the healthcare institutions which serve them. The understanding afforded by the midwifery notes can contribute to exploration of the care provided; what went well and what might be improved.41 This is true both in the immediate clinical circumstance, for the later reflective understanding of events by the individuals involved,42 and from the perspective of professional review processes.43,44 4.5. Audits and clinical reviews Effective record-keeping contributes to accurate auditing processes and clinical reviews11,16 and facilitates exploration of the provision of care at individual, departmental, hospital and national levels.27,45 Audit processes allow for consideration of the effectiveness of the service and identification of priority areas for further exploration.29 Likewise, reviews of critical clinical incidents support the development of the service, and demonstrate accountability and the transparency of service provision.41 These processes contribute to the understanding of all parties, when events are explored with a focus on the improvement in the systems of care.40 Clinical documentation forms the basis for exploring and understanding events as they unfolded.27,46
4.6. Data collection Meaningful interpretation of maternity outcomes, specific aspects of care provided and the exploration of service provision relies on accurate collection of qualitative and quantitative information.35,41 As a result of this need for clear data to support and evaluate the quality and safety of care, hospitals, professions and government departments have clear minimum requirements for data collection. Midwifery documentation informs the collection of midwifery statistics, hospital statistics and national statistics.27 This information has the potential to improve the quality and safety of services provided by hospitals and the maternity system.47–49 Additionally, these data can be used to support the development of
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the midwifery body of knowledge, through research and education processes.29,45,50 4.7. Contribution to the research environment and education Midwifery notes provide evidence which informs the purposes of research29 and also a platform to explore “best” practice.16,41 The maternity record establishes evidence of midwifery knowledge and relationships, and provides an opportunity to articulate the priorities of women and midwives. The record then can be used for educational purposes and for research. By thoroughly and accurately documenting the detail of their work, midwives can influence and guide the knowledge of current and aspiring members of the profession,46 contributing to the experience and development of student midwives27,40,45 and informing the understanding of other interested parties.38,51 The importance of the accuracy of the maternity record is accepted, as the ability of researchers to interpret the care provided, the sequence of events which have occurred and the outcomes of the recipients of care, is determined largely by the content of the record.29,41 4.8. Makes midwifery work visible As a result of the contribution to clinical, institutional, national and academic environments, midwifery record-keeping has the potential to improve the visibility of the work of midwives.51,52 For this reason, it is important that documentation is detailed enough to provide evidence of the thoroughness of the care provided. A detailed record articulates the role that the midwife fulfills for the woman and her family, and conveys the expert knowledge and skills of the midwife.29,52,53 What is documented becomes visible to many parties, including those responsible for the funding and planning of maternity services.16,54 This has potential to improve resources available to women, babies and midwives29,33,48,49 and may impact the development of policy relevant to midwifery practice.50,55 A related consideration is the potential for a written record of midwifery care, which is based upon the shared language of women and midwives, to communicate the nature of midwifery work.51,52 Carefully developed midwifery notes can serve to identify and emphasise the many ways in which midwifery care is both related to, and differs from, obstetric care.27 Midwifery documentation records the breadth of midwifery care and, in this way, helps to define and frame midwifery practice. The complexity, depth and holistic nature of midwifery can be articulated in the clinical record,34,38 serving to clarify the unique and personal characteristics of the midwife-woman relationship.27,56 This concept is captured by Miller and Wilkes:25 Documentation which is an artful blend of both the objective findings and the social/emotional context may articulate additional dimensions of midwifery knowledge as effectively as empirical knowledge derived from research, and deserves to be as highly valued by health professionals as it is by women (p. 416).
4.9. Reflection on practice and a record of experience for midwives As documentation makes midwifery work more visible to institutions, policy makers and the public, so it can also make this work more visible to the individual midwife, facilitating reflection on practice.57 In the process of recording the clinical notes the midwife is able to reflect on the potential courses of action available for the woman and/or baby and to consider the most appropriate care plan. The care provider may, therefore, understand the experience, circumstances and clinical condition of the
person receiving the care, and this provides opportunity for more effective individualisation of services.14,28,34 For example, in a continuity of care relationship the midwifery record will help the midwife remember previous conversations and decisions relevant to the care of her client.46 This will enhance the partnership relationship and improve care planning.25 As a retrospective tool, midwifery documentation allows the midwife to look back on her work and explore her communications, the decisions made with the woman, actions taken and plans developed.29 She can evaluate her responses and consider the ways in which the experience and outcomes of her clients may have been affected.14 The maternity notes are, therefore, a record of experience for the midwife, of her practice, her relationship with the woman and other parties, and can afford her a particular insight into her own professional development.27 4.10. Professional expectation and demonstration of professional accountability The midwifery record demonstrates the midwife’s accountability but also supports her ability to be accountable. In Aotearoa/ New Zealand, the regulatory and professional organisations for midwifery practice clearly identify the requirement for midwives to write a meaningful record for each and every midwifery encounter.2,3 Documentation allows the midwife to measure her practice against quality and professional standards.27 Thorough documentation demonstrates the midwife’s responsibility for her work.36,58 It supports her to meet professional requirements such as recertification processes.59 The visibility of midwifery care, within midwifery record-keeping, enhances the accountability of individual midwives30,51 and the transparency of the maternity service.41,60 Meeting these professional expectations for documentation, and thoroughly recording the care provided to women, allows the midwife and others to demonstrate whether the midwife has behaved in a manner considered reasonable by her peers.34,58,61 4.11. Legal record The maternity record for a woman and baby constitutes a legal reference in circumstances which necessitate a review of the care provided, or of the outcome, for the mother and/or the infant.29 Thorough documentation provides a summary of events which have occurred and details of the care provided.18,30 It therefore demonstrates, step by step, the critical analysis made by the midwife, her awareness of the developing clinical circumstance and whether the actions taken were appropriate.34,51 The midwife’s understanding of requirements for the structural aspects of the record is informed by the legal frameworks available within the midwife’s practice context, and these support midwives to meet their professional record-keeping accountabilities.7–10 A number of authors have provided clear discussion of the legal and structural considerations for record-keeping and these aspects are frequently explored in international literature on the topic of documentation.31,36,54,62–64 The extent to which health professionals should focus on the use of healthcare records for legal purposes is also debated within the literature.58,65 There is no doubt that midwifery documentation is a valuable resource for clinical review and audit processes. However, many authors contend that the value of health records extends well beyond legal and regulatory parameters.34,55,56 4.12. A narrative of experience for women Midwifery documentation has the potential to enhance the experience of women accessing maternity care.5,24 A woman’s
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midwifery notes will serve to clarify her understanding of events and record significant aspects of her experience, as well as her priorities for care.15,66 The maternity record supports her current understanding of her care and care arrangements, and documents her maternity journey in a way which she can reflect on, in the future.67 The documentation of explanations and information provided for women in woman-held notes will enhance the autonomy of the mother and her family.16,23,68,69 When a woman can refer to a clinical record which is developed specifically for her circumstance and consideration, she has increased opportunity to take responsibility for her own wellbeing and that of her baby.5,15,24,70,71 Midwifery documentation has the potential, therefore, to improve the participation of women in their care.15,16,72 The midwifery record may contribute to, and represent, a woman’s experience of her maternity care in a way which articulates more than clinical events. The priorities and preferences of pregnant, birthing and postnatal women may be made more visible to all parties, enhancing the quality and safety of maternity care.25,66 4.13. Implications and recommendations There are identified professional and legal parameters for midwifery record-keeping. However, the midwifery profession will benefit from further understanding of documentation, including the priorities for the maternity record defined by women, midwives, allied professions and relevant professional and regulatory bodies. Further research is needed to clarify these priorities and to develop clear guidance for midwives as to how they might satisfy all aspects within the woman’s maternity record.
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each woman and baby. Thorough and accurate record-keeping explains the care planned by, and for, the woman and details the actions of the midwife. Documentation contributes to the demonstration of midwifery accountability and articulates the work undertaken by midwives. It enhances the collection of relevant and accurate statistics at individual, hospital and national levels and contributes to the research environment. Midwifery records have the potential to improve our understanding of the maternity needs of women, their families and the community, whilst clarifying the professional contribution of the midwife. These clinical notes constitute a legal record which demonstrates the midwife’s practice and development, and may support audit and clinical review processes. This multi-dimensional component of midwifery care can enhance the relationships of, and collaboration between, care providers and contribute to service provision at a broader level. The development of a meaningful record supports continuity of care for women and seamless sharing of care between different health professionals. Midwifery documentation records details of the relationship between a woman and her midwife and the decisions they make together. The maternity care record can enhance the experience of both women and midwives, by communicating the priorities of women and articulating the midwife’s practice and expertise. Acknowledging these diverse purposes of the documentation of midwifery care, further research can contribute an understanding of how we might meet these purposes within the context of the woman’s maternity record.
Funding No external financial support was received for the publication of this article.
5. Conclusion Acknowledgments Midwifery documentation, as the record of the maternity care journey of women and babies, is a critical component of the work of midwives. It has an essential role in the safe provision of care to
I would like to acknowledge Otago Polytechnic for support in the preparation of this publication.
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Appendix A Fig. A1.
Fig. A1. One PRISMA diagram of literature searching process.
Appendix B Table A1. Table A1 One literature summary table. Authors
Title
Description
Andrews and St Aubyn36
‘If it’s not written down; it didn’t happen . . . ’
Discussion of the importance of timely, accurate and Authors summarise the impact of good thorough record-keeping documentation processes and highlight the potential impact of poor record-keeping. They identify that the documentation of interactions between nurses and patients is important.
Baskaran et al.16
Managing information and knowledge within maternity services: Privacy and consent issues
A “mixed-mode methodology of literature reviews, structured questionnaires and semi-structured interviews” (p198)
Summary
The data available from clinical records can support the provision of maternity services and improve health outcomes. It can also inform funding and planning, research and policy development.
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Table A1 (Continued) Authors
Title
Description
Summary The authors address the security of electronic health records.
Blair and Smith30
Nursing documentation: Framework and barriers
Literature search using CINAHL and MEDLINE
Nurses continue to struggle to find the time and effective strategies to document adequately in practice. There are many barriers to acceptable nursing documentation. Frameworks for documentation may help streamline record-keeping processes.
Buus and Hamilton51
Social science and linguistic text analysis of nurses' records: A systematic review and critique
Systematic searching undertaken in databases and citation indexes
The use of language which is highly technical, abbreviated, and often not generic, may undermine the experience of the reader. The practise of nursing is often not visible in nursing records which are heavily medically dominated.
Cheevakasemsook et al.45
The study of nursing documentation complexities
Multiple methods of exploration were used:
Six themes were identified to summarise the complexities of nursing documentation: Interviewing, participant observation, nominal group Disruption of documentation processing, focus groups, nursing record audits and Incompleteness in charting time and motion study of nursing care Inappropriate charting Limited nurses competence, motivation and confidence Ineffective nursing procedures Inadequate nursing auditing, supervision and staff development
Irving et al.38
Discursive practices in the documentation of patient assessments
Foucauldian analysis of 45 patient records
Jefferies et al.34
A meta-study of the essentials of quality nursing documentation
A synthesis of literature about nursing documentation 7 themes identified the “essentials of quality nursing documentation”: Theme 1: Nursing documentation should be patient centred Theme 2: Nursing documentation must contain the actual work of nurses including education and psychosocial support Theme 3: Nursing documentation is written to reflect the objective clinical judgement of the nurse Theme 4: Nursing documentation must be presented in a logical and sequential manner Theme 5: Nursing documentation should be written as events occur Theme 6: Nursing documentation should record variances in care Theme 7: Nursing documentation should fulfil legal requirements
Kelley et al.28
Electronic Nursing Documentation Integrative review of the literature exploring the as a Strategy to Improve Quality of relationship between electronic nursing Patient Care documentation and patient care
Zegers et al.41
Quality of patient record keeping: Retrospective review of patient records from 21 Dutch Poor record quality seemed to be associated with an indicator of the quality of care? hospitals. poorer outcomes for patients. Additionally, reduced quality of record-keeping impacted the ability of the reader to review the notes and accurately identify outcomes.
Three identifiable discursive practices were discerned to be used by nurses in their records: Medical Nursing Informal The authors conclude that these nursing documentation practices identify and contribute to the definition of nurses and the nursing profession.
Discussion of the importance of documentation for supporting the critical reflection, analysis and care planning of nurses. Nurses opinions about, and perceptions of, electronic documentation are well represented in the literature. However, the impact of electronic nursing documentation on patient safety and outcomes remains unclear.
Articles which formed the most significant basis of the discussion are included here.
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