What factors affect documentation by midwives? A prospective study assessing relationship between length of shift, workload and quality of note keeping

• The quality of note keeping deteriorated between the middle and the end of the 12-h shift, but it appeared unaffected by workload.
• There was no statistically significant difference in note-keeping standards between day and night shifts.
• Partogram documentation was poorer in the middle compared to the beginning of the shift, and there was no statistical difference between day and night shifts.
• Partogram completion appeared to be influenced by the women:midwife ratio as well as progression through a shift.

ObjectiveThe objective of this study was to assess the association between the quality of basic note keeping and partogram documentation with progression of shift and workload on labour ward.DesignThis was a prospective observational study.SettingThe setting of this study was a labour ward of a teaching district hospital in an inner city London hospital.MethodsIntrapartum notes and partograms of 61 consecutive labouring women were assessed for quality of midwifery documentation at the beginning, middle and end of a 12-h shift.MeasurementsThe measurements of this study were a basic note-keeping composite score based on validated criteria by the Nursing and Midwifery Record Keeping Guidance 2010 and a partogram completion score based on the National Institute for Clinical Excellence (NICE) Guidelines for Intrapartum Care 2007.FindingsThe basic note keeping deteriorated between the middle and the end of the 12-h shift, but it appeared unaffected by workload, with no statistically significant difference between day and night shifts. Partogram documentation was poorer in the middle compared to the beginning of the shift, and there was no statistical difference between day and night shifts. Partogram completion appeared to be influenced by women: midwife ratio as well as progression through a shift.Key conclusionsThe basic note keeping and partogram documentation were best at the beginning of the shift, and fatigue may play a role in poorer documentation towards the middle and the end of the shifts.Implication for practiceAppropriately scheduled breaks especially during the final third of the shifts may help improve the quality of documentation.