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

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