Identification of the Application of Midwifery Care Documentation by Midwives in RSUD Pulang Pisau
DOI:
https://doi.org/10.51699/ijhsms.v3i4.133Keywords:
Midwife, DocumentationAbstract
Midwifery documentation is important because it serves as legal evidence in health care, helping to enforce accountability and liability related to patient care. It also serves as a source of information about the patient's health status and an instrument of protection for patients and midwives. The use of standardized documentation methods such as SOAP has significant benefits in organizing midwives' thought processes, but there are still midwives who have not adopted it. Further efforts are needed to improve understanding and application of documentation standards in midwifery practice. Identifying Integrated Patient Progress Notes by Midwives at Pulang Pisau Regional Hospital in 2023. This study used a descriptive method that describes integrated patient development records by midwives at Pulang Pisau Regional Hospital. The samples in this study were 45 midwives who were in the delivery room, postpartum room and obstetric clinic room. Based on research from 45 midwives, the majority were 21-40 years old, 14 midwives (31.1%) had DIV Midwifery and S1 Midwifery education, 32 midwives (71.1%) had a working period of 6-10 years. 27 respondents (60%) of the completeness of integrated patient progress notes by midwives in the delivery room, postpartum room and obstetric clinic room of Pulang Pisau Hospital were incomplete, and as many as 18 respondents (40%) with complete progress notes. The majority of integrated patient progress notes made by midwives in the labor and delivery room, postpartum room, and obstetric clinic room of Pulang Pisau Regional Hospital were incomplete, with only a small proportion being complete. This suggests the need for improvement in the documentation process and integration of patient progress notes by midwives at RSUD Pulang Pisau.
References
B. Mure, “Faktor-faktor yang mempengaruhi kinerja bidan dalam pendokumentasian buku KIA di wilayah kerja Puskesmas Muara Badak tahun 2020,” pp. 1–137, 2020.
B. Nurul Hikmah Annisa and M. Keb, “Buku Ajar Dokumentasi Kebidanan Penerbit Cv.Eureka Media Aksara”.
C. Yunie, S.ST.,M.Kes, “Gambaran Penerapan Pendokumentasian Asuhan Kebidanan Dibps Wilayah Kerja Kecamatan Singaparna Tahun 2015,” Jurnal Kesehatan Bidkesmas Respati, vol. 2, no. 7, pp. 63–71, 2016, doi: 10.48186/bidkes.v2i7.74. DOI: https://doi.org/10.48186/bidkes.v2i7.74
Chalmers, B. (2006). Maternal and Newborn Care in Midwifery Practice: Global Perspectives and Challenges. Oxford University Press.
D. A. Palifiana and S. Wulandari, “Penerapan pendokumentasian asuhan kebidanan pada bidan praktik mandiri di kabupaten bantul,” Jurnal Keperawatan Intan Husada, vol. 4, no. 1, pp. 39–49, 2017.
D. A. Palifiana, “Hubungan pendidikan bidan dengan penerapan pendokumentasian asuhan kebidanan pada bidan praktik mandiri di Kabupaten Bantul,” in PROSIDING KONTRIBUSI HASIL PENELITIAN DAN PENGABDIAN MASYARAKAT DALAM PROGRAM SUSTAINABLE DEVELOPMENT GOALS (SDGs), Semarang: UNIMUS | Universitas Muhammadiyah Semarang, 2016. [Online]. Available: https://jurnal.unimus.ac.id/index.php/psn12012010/article/view/2127.
Dawson, A., & Homer, C. S. E. (2014). Midwifery care: Meeting the needs of women and families. The Lancet, 384(9948), 1129-1130.
Finlay, B., & Sandall, J. (2009). Midwifery care: A key to safer birth? The Lancet, 374(9698), 1005-1006. DOI: https://doi.org/10.1016/S0140-6736(09)61815-8
Fraser, D. M., Cooper, M. A., & Nolte, A. G. (2019). Myles Textbook for Midwives (17th ed.). Elsevier Health Sciences.
Gilmour, C., & McCarthy, A. (2015). Effective documentation in midwifery practice: A crucial component of patient safety. British Journal of Midwifery, 23(9), 654-658. DOI: https://doi.org/10.12968/bjom.2015.23.9.654
Guarino, R., & Gurr, R. (2011). Medical record keeping and its importance in obstetric and midwifery care. Journal of Midwifery & Women’s Health, 56(5), 412-416.
I. P. Setyaningtyas, S. Wahab, P. Piksi, and G. Bandung, “Analisis Pengisian Catatan Perkembangan Pasien Terintegrasi Guna Menunjang Standar Pelayanan Minimal di RSUD dr. Soedirman Kebumen,” Pendidikan Tambusai, vol. 5, no. 3, pp. 7130–7133, 2021.
Ivers, R., & Mark, A. (2016). Quality of maternal health records and their impact on health outcomes. Journal of Health Management, 18(4), 475-482.
Jenkinson, B., & Kruske, S. (2014). Women’s maternity care experiences: Midwifery continuity, documentation, and care provision. Midwifery, 30(1), 15-19.
Jordan, S., & Hughes, D. (2021). The influence of clinical documentation on the quality of maternal care. Journal of Maternal-Fetal & Neonatal Medicine, 34(7), 1-9.
Larkins, S., & Lander, R. (2017). Standardization of care documentation in midwifery. BMC Health Services Research, 17(1), 23.
Marchant, T., & Bhutta, Z. A. (2020). Improving maternal and neonatal outcomes: Importance of midwifery documentation. Global Health Action, 13(1), 45-56.
Martin, L. J., & Cox, J. (2013). Accuracy in midwifery documentation and its relation to patient safety. Journal of Clinical Nursing, 22(5-6), 785-794.
McCarthy, R., & Gill, M. (2017). Best practices in midwifery documentation and record-keeping. Midwifery Matters, 33(4), 22-30.
R. Pitriani and R. Andriyani, “Abstract Implementation of Midwifery Care Documentation With the S-O-a-P Method in the Practice of Mandiri Midwives,” JKM (Jurnal Kebidanan Malahayati), vol. 7, no. 3, pp. 544–547, 2021. DOI: https://doi.org/10.33024/jkm.v7i3.3641
S. Poerwaningsih, “Penerapan standar asuhan kebidanan pada ibu hamil fisiologis trimester I - Google Books,” in P4I, 2022.
Sinclair, M., & Gardner, J. (2011). Critical aspects of midwifery documentation in improving patient care. International Journal of Midwifery, 28(4), 425-432.
Stephenson, P. (2015). Midwifery documentation: A tool for quality care and accountability. Nursing and Midwifery Research Journal, 11(1), 65-72.
