Manpreet Kaur, Kavita Narang, Avinash Kaur Rana, Neelam Aggarwal

Abstract:

Background: Documentation is pivotal in maternity nursing. It is an evidence of work or care provided by a midwife to the antenatal, intranatal, and postnatal mothers. Clear, accurate, and accessible documentation is an essential element of safe, quality and evidence-based nursing practice.

Objective: To nd out the current documentation practices of the maternal nursing assessment and care.

Methods: A cross sectional descriptive study was conducted among thirty- ve nursing personnel working in tertiary care level hospital of the central government institute. Ethical approval from Institute Ethics Committee and permission from the Head, Department of Obstetrics and Gynecology was taken. An informed written consent from the study participants was obtained. The study participants were selected by purposive sampling technique. Data was collected through interview and observation using validated semi-structured interview schedule and observation checklists respectively. Data was analysed with SPSS 20.

Results: Results revealed that the checking of vital signs and administration of medication were documented by all of the study participants whereas urinalysis was documented by 60% of the study participants. Rest of the activities related to maternal assessment (such as assessment of warning signs, fetal wellbeing parameters, condition of breast, assessment of episiotomy and perineum, elimination patterns and emotional status) and maternal care such as assisting in various procedures (Per vaginal examination, blood transfusion, Amniotomy, induction of labour, Non Stress Test, suture removal etc.),preparation for delivery, teaching about comfort measures, diversion activities, bearing down technique, prevention of infection practices, diet and exercises, breast care, care of episiotomy and perineum, lochia were not documented by study participants. All study participants reported that they don’t have any documentation record sheet where they can record their health talks and evaluation of nursing care. Conclusion: Poor documentation practices of maternal nursing care were found in the present study. A standardized document is required to record the maternal nursing assessment, care, evaluation of care and to recommend care to nursing personnel coming for next shift.

Keywords: Documentation; Maternal care; Maternal assessment; Midwifery; Nursing care records; Record keeping.

Address for correspondence:

Dr Kavita Narang Lecture, NINE, PGIMER, Chandigarh

Background:

Documentation sets up the professional accountability as it demonstrates that nursing knowledge, judgement and skills have been used for the nurse-patient relationship as per the  standards  of  practice  for  nurses.1 American nurses association states that clear, accurate, and accessible documentation is an essential element of safe, quality, evidence- based nursing practice. The Registered Nurses are responsible and accountable for the nursing documentation used in an organization.2   Documentation of health care records must provide an accurate description of each patient/client’s episodes of care or contact with health care personnel. The healthcare record should be available for every client to assist with assessment and treatment, continuity of care, clinical handover, patient safety and clinical quality improvement, education, research, evaluation, medico-legal, funding and statutory requirements. Health care record management practices must comply with this policy.3

Good standards of record keeping are linked with improving the quality of patient care and are also a means of protecting and safeguarding the professional accountability Midwifery Council mandates that all records related to women and her baby should be kept securely for 25 years and women should be able to access their records whenever required.8  The present study was conducted with an objective to assess the current documentation practices regarding maternal assessment and care.

Materials and methods:

A cross sectional descriptive study was conducted among thirty-ve nursing personnel working in tertiary care level hospital of the central government institute to nd out the current documentation practices of the maternal nursing care. Ethical clearance from the Institute Ethics Committee was taken (INT/IEC/2017/254 dated 22 March, 2017). Permission from Head, Department of Obstetrics and Gynecology was taken wide letter number NINE/337 dated 30 Jan,2017. An informed written consent from the study participants was obtained. Nursing personnel working in of  nurses.4    American  college  of  Nurse- Maternity ward, Gynae ward, Labour room midwives advocates that midwifery care should be documented in format which is accessible  and  complete.5     There  is  an and its extension were selected by purposive sampling technique.

Data related to documentation practices of increasing demand for accessible, detailed health care information and record keeping systems to both providers and patients that provide information across the continuum of care and support quality measurement and improvement. Having the appropriate tools in place is vital to ensuring that the continuity, safety, and quality of care are supported across the multiple handovers between various providers involved in a patient’s care.6 Hospital administrators, practitioners and researchers view record keeping as a crucial element leading to continuity of care, safety, Antenatal, Intranatal, Postnatal nursing assessment, nursing care activities/ procedures for clients, evaluation of nursing care and health talks was collected through Interview and observation using     semi- s t ructured i n t e rview schedule and observation checklists. The tools were validated by the experts from the obstetrics nursing, community health nursing and obstetrics medicine. Interview schedule comprised of open ended and close ended questions regarding documentation practices. It explored various maternal assessment and quality  care,  and  compliance.7     National care activities performed and the availability of standardized record for documentation and recommendation of care for nursing personnel. It had following parts:a)Socio- demographic and work prole b)Nursing assessment of mother, c) Nursing care activities/ procedures for mothers, d) Evaluation of nursing care, e)Health talks about maternal care.

Observation Checklists included antenatal, intranatal, postnatal maternal assessment and care activities and simultaneously recording of documentation of maternal assessment and care activities. Observation checklists used were: a) Checklist to assess documentation practices of antenatal care: It had following parts: i)Antenatal assessment practices, ii) Preterm risk factors, iii) Fetal assessment, iv) Antenatal care practices. B) Checklist to assess documentation practices of intranatal care: It had following parts: i)Intranatal assessment practices,   ii)   Intranatal   care p r a c t i c e s , C ) C h e c k l i s t t o a s s e s s documentation practices of postnatal care: It had following parts: i)Postnatal assessment practices including vitals, assessment of breast, uterus, lochia, perineum/episiotomy, bladder, bowel, hygiene. ii)Postnatal care practices including teaching about breastfeeding,   diet,   exercise,   medication a d m i n i s t r a t i o n , b a c k m a s s a g e , perineum/episiotomy care, lochia, return of menses, postpartum warning signs, postpartum mental health, family planning.

Thirty ve study participants were interviewed regarding documentation practices and then they were observed for their routine nursing activities and their documentation practices during morning, evening and night shifts. 2-4 participants were observed in each shift and total 5 antenatal mothers, 5 intranatal and 8 postnatal mothers were observed while working in maternal care units. Data was analysed with SPSS 20.

Results:

Self reported Maternal assessment and care practices: The maternal assessment and care practices mentioned by the study participants during interview are shown in gure1 and gure 2 respectively. The most common assessment practice reported by nursing personnel was vital signs (82%) followed by assessment of breast(57%), lochia (57%)and elimination pattern(57%) (gure1)whereas the most common care practices reported by nursing personnel were breastfeeding (62%)followed by activities such as diet and w a t e r i n t a k e ( 5 4 % ) , m e d i c a t i o n administration(43%), teaching perineal care( 40 %) and assisting in various procedures(40%)(gure 2).

Self-reported Documentation practices of nursing personnel:

Maternal assessment practices: Table 1 indicates that half of the study participants (51.4%) mentioned that there was no separate document available to record maternal nursing assessment whereas other study participants (48.6%) mentioned that they use BP chart, I/O Chart, GDM chart, Graph chart and Abdominal girth chart for record keeping of maternal assessment practices.

Maternal care practices: Majority of study participants ( 77. 1%) responded that document to record maternity nursing care activities is unavailable whereas other study participants (22.9%) said that they document their maternal care activities in treatment chart, B.P.Chart (remarks column), delivery book and report book.

Evaluation/ Recommendation/Handover Practices: All study participants (100%) reported that there is no document available for them to guide or document the ‘topics of health talks’ which should be or have been provided for the care of mother. Similarly, all study participants (100%) mentioned that there is non-availability of any record to document the ‘evaluation of nursing care’ and ‘recommendation of nursing care’ (82.9%) to the staff coming on next shift. Some (17.6%) nursing personnel responded that they recommend nursing care in report book and in the remarks column of the treatment chart and B.P. chart.

Observation of documentation practices

Antenatal Assessment and care Practices: Table 2 indicates that among the antenatal assessment practices, vitals were documented by all (100.0%) the study participants whereas Urinalysis was documented by 60.0% study participants .On the other hand, among  Antenatal  care  practices,  the a d m i n i s t r a t i o n o f m e d i c a t i o n w a s documented by all (100%) nursing personnel whereas the teachings provided by nursing personnel on diet and water intake, fetal wellbeing parameters (DFMC, NST), about warning signs in pregnancy were not documented.

Table 1: Self reported documentation practices of nursing personnel regarding maternal care

N=35

 

  Variables n(%)
MATERNAL ASSESSMENT PRACTICES  
1 Perform systematic nursing assessments of all mothers

·  No

·  Yes

 

16.0(45.7)

19.0(54.3)

2 Availability of separate document to record nursing assessment

·  No

·  Yes

If yes, what all documents are available?

·  BPa chart

·  I/Ob Chart

·  GDMc chart

·  Graph Chart

·  Abdominal girth chart

 

18.0(51.4)

17.0(48.6)

17.0(100)

12.0(70.6)

8.0(47.1)

8.0(47.1)

1.0(5.9)

MATERNAL CARE PRACTICES  
 

4

 

 

 

 

 

5

Availability of any record to:

Document maternal nursing care activities

·  No

·  Yes

If yes, what all documents are available?

·  Treatment chart

·  BP chart (remarks)

·  Report Book

·  Delivery Book

Guide and Document health talks to be provided about maternal care

·  No

 

27.0(77.1)

8.0(22.9)

6.0 (75.0)

4.0 (50.0)

2.0 (25.0)

1.0 (12.5)

35.0(100)

EVALUATION/ RECOMMENDATION/HANDOVER PRACTICES
 

7

 

6

Availability of any record to:

Document evaluation of nursing care

·  No

·  Yes

Recommend nursing care to nursing personnel coming on next shift

·  No

·  Yes

If yes, what all documents are available?

·  Report book

·  Treatment/ B.P Chart ( remarks)

 

35.0(100)

—–

29.0(82.9)

6.0(17.1)

2.0 (33.3)

2.0 (33.3)

a-Blood pressure, b- intake/output, c- Gestational Diabetes Mellitus

Table 2: Antenatal nursing assessment, care and corresponding documentation by study participants

N=5

Items Investigator’s Observation of Study participants
Performed

n=5(%)

Documented

n=5(%)

ANTENATAL ASSESSMENT PRACTICES
Vitals(Temperature, Pulse, Respiration, Blood Pressure)

Urinalysis(Urine amount, Sugar, Albumin)

5.0(100)

3.0(60.0)

5.0(100)

3.0(60.0)

ANTENATAL CARE PRACTICES
Administration of medication Diet and water intake

Fetal wellbeing parameters (DFMCa, NSTb) Warning signs in pregnancy

5.0(100)

2.0(40.0)

1.0(20.0)

1.0(20.0)

5.0(100)

—–

—–

—–

a- Daily fetal movement count, b- Non stress test

Table 3: Intranatal nursing assessment, care and corresponding documentation by study participants

N=5

Items Investigator’s Observation of Study participants
Performed

n=5(%)

Documented

n=5(%)

INTRANATAL ASSESSMENT PRACTICES    
Vitals(Temperature, Pulse, Respiration, Blood Pressure) Urinalysis(Urine amount, Sugar, Albumin)

Uterine Contractions

Fetal heart rate (FHR) Hygiene of mother

5.0(100)

3.0(60.0)

3.0(60.0)

2.0(40.0)

2.0(40.0)

5.0(100)

3.0(60.0)

INTRANATAL CARE PRACTICES    
Administration of medication Diet and water intake

Assist in Various procedures (P/Va examination, ARMb, IOLc,NSTd)

Preparation for delivery Comfort measures Diversion activities Bearing down

Prevention of infection practices

5.0(100)

2.0(40.0)

5.0(100)

4.0(80.0)

3.0(60.0)

2.0(60.0)

3.0(60.0)

2.0(40.0)

5.0(100)

a-Per vagina, b- Articial rupture of membranes, c- induction of labour, d-Non stress test Intranatal Assessment and care Practices: Table 3 indicates that among the intranatal assessment practices vitals were documented by all the study participants whereas Urinalysis was documented by 60.0% study participants .On the other hand, among intranatal care practices, the only activity d o c u m e n t e d b y t h e s t u d y participants(100.0%) was administration of medication whereas the practices such as preparation for delivery ,assist in various procedures (Per vaginal examination, blood

Table 4: Postnatal nursing assessment, care and corresponding documentation by study participants

N=8

Items Investigator’s Observation of Study

participants

Performed

n=8(%)

Documented

n=8(%)

POSTNATAL ASSESSMENT ACTIVITIES    
Vitals (Temperature, Pulse, Respiration, Blood Pressure) 8.0(100)

 

4.0(50.0)

5.0(70.0)

 

1.0(12.5)

2.0(25.0)

 

2.0(25.0)

3.0(37.5)

2.0(25.0)

 

1.0(12.5)

8.0(100)

 

 

 

 

Breast
· Nipples &Breast engorgement
· Milk Adequacy
Lochia & Episiotomy
· Colour & Amount (no. of pads)
· Assessment of Episiotomy(pain)
Elimination
· Voiding
· Bowel sounds
· Constipation
Hygiene (Brushing &Bathing)
POSTNATAL CARE ACTIVITIES    
Perineal care Breast care

Administration of medication Breastfeeding

· Positions & Lathing

· Burping

· Frequency of feeding

· Expressing and storing breast milk Episiotomy and incision care

7.0(87.5)
8.0(100) 8.0(100)
2.0(25.0)
3.0(37.5)
4.0(50.0)
1.0(12.5)
3.0(37.5)

 

transfusion, Amniotomy, induction of labour, Non Stress Test), teaching about diet and water intake, diversion activities, comfort measures , bearing down, prevention of infection practices were not documented.

Postnatal Assessment and care Practices: Table 4 indicates that among the postnatal assessment practices vitals were documented by all the study participants whereas assessment of Breast, Lochia & Episiotomy, elimination pattern, hygiene were not documented by study participants . On the other hand, among postnatal care practices, the only activity documented by the study participants(100.0%) was administration of medication whereas the practices such as perineal care, breast care, health talk related to breastfeeding , Episiotomy and incision care were not documented.

Discussion:

Documentation has multifarious roles in healthcare system. It ensures that standardized level of care has been provided to clients admitted in health care facility. A standardized document is required to maintain uniformity of care. Documentation ensures that all clients receive a basic essential level of care.

The present study made it abundantly clear that the documentation of the maternity nursing care is poor. The most commonly documented maternal assessment practices are vitals and urinalysis whereas maternal care practice is administration of medication. Maternal care activities such as assessment of warning signs, fetal wellbeing parameters, condition of breast, episiotomy, lochia, elimination patterns and emotional status are not documented at all. Similar ndings are reported by many studies where they found poor documentation in intraprtum care and Janani Suraksha Yojana (JSY). 9,10 The study on JSY program reviewed 1239 records and assessed records of twenty elements of care such as clinical history, admission details, care during delivery, and postnatal period, and details of discharge teachings. The study reported that only 1.9% documented advice at discharge, 13.8% documented postnatal blood pressure and 35.3% documented fetal heart rate and it concluded that the quality of documentation in clinical records of women who delivered at 73 primary, secondary, and tertiary level facilities in three districts of Madhya Pradesh  was poor.9  The  other study on documentation of Intrapartum care in a Swedish maternity unit, considering in relation to World Health Organization recommendations for the care of women in normal birth showed no documentation of emotional aspects of women and fetal heart rates and similar results are reported by studies on Intrapartum care .10

Nursing personnel spend considerable amount of time in teaching various activities related to maternal assessment and care but these activities are not documented. Crucial information related to antenatal (fetal wellbeing parameters, DFMC, NST, warning signs), intranatal (preparation for delivery ,assist in various procedures viz. Per vaginal examination, blood transfusion, amniotomy, Induction of labour, Cardiotocography, teaching about diet and water intake, diversion activities, comfort measures , bearing down ,prevention of infection practices) and postnatal (breast, perineum, & Episiotomy, Lochia, elimination pattern, hygiene) is not documented.

Nursing personnel reported that the documentation charts available were BP chart, I/O Chart, GDM chart, Graph chart, Abdominal girth chart, delivery book, report book however they don’t have any dedicated documentation record for the documentation of maternal assessment and care of the clients admitted in obstetrics units so they utilize the remarks columns of the above-mentioned charts to document the same. Nursing personnel verbalized the need to develop a d o c u m e n t w h e r e m a t e r n a l n u r s i n g assessment, care, evaluation, health talks and recommendation/ handovers can be documented efciently.

Conclusion: The present study concluded that the record keeping of maternal assessment and care is very poor as compared to the work done by the nursing personnel. Hence it is recommended to develop a standardized document to record the maternal nursing assessment, care and evaluation of care for the nursing personnel working in maternity units.

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