Woman-centred care and integrated electronic medical records within Australian maternity settings: Point prevalence audit and observational study

Abstract

ObjectiveTransition to paperless records brings new challenges to midwifery practice across the continuum of woman-centred care. There is limited and conflicting evidence on the relative benefits of electronic medical records in maternity settings. This article aims to inform the use of integrative electronic medical records within the maternity services’ environment with attention to the midwife-woman relationship. DesignThis descriptive two-part study includes 1) an audit of electronic records in the early period following implementation (2-time points); and 2) an observational study to observe midwives’ practice relating to electronic record use. SettingTwo regional tertiary public hospitals ParticipantsMidwives providing care for childbearing women across antenatal, intrapartum and postnatal areas. Findings400 integrated electronic medical records were audited for completeness. Most fields had high levels of complete data in the correct location. However, between time 1 (T1) and time 2 (T2), persistent missing data (foetal heart rate documented 30 minutely T1 36%; T2 42%), and incomplete or incorrectly located data (pathology results T1:63%; T2 54%; perineal repair T1 60%; T2 46%) were identified. Observationally, midwives were actively engaged with the integrative electronic medical record between 23% to 68% (median 46%; IQR 16) of the time. ConclusionMidwives spent a significant amount of time completing documentation during clinical episodes of care. Largely, this documentation was found to be accurate, yet exceptions to data completeness, precision and location remained, indicating some concerns with software usability. Implications for practiceTime-intensive monitoring and documentation may hinder woman-centred midwifery care.