Abstract

Documentation of Midwifery is a recording and reporting evidence owned by midwives in performing care records that is useful for the interest of patient, midwivesand health team. Documenting can be applied to the Subjective, Objective, Analysis and Planning (SOAP) method. This study aimed to determinefactors associated with the implementation of the SOAP documentation by midwife in Pekanbaru City in 2016. This study was a quantitative analytical observationalstudy with analytic cross-sectional study design. The population was all Independent Practice Midwives or maternity hospital in Pekanbaru City witha total sample of 191 midwives with systematic random sampling procedure. Data were collected through interview using questionnaires and the midwives’documentation records. The results showed that variables which affected the implementation of SOAP documenting method were the documentation format(POR 15.988), supervision (POR 6.366) and attitude (POR 2.729). This means that midwives with the unavailable format were 16 times at risk of carrying outthe documentation not in accordance with SOAP, while the midwives who were never supervised were 6 times at risk and the midwives with negative attitudeswere 3 times at risk.

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