Related Experiment Video
Updated: Apr 27, 2026
09:00
TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
Published on: April 13, 2021
5.3K
[Requirements and current state of birth documentation in Germany]
N Syllwasschy1, K-G Noé2, W Hatzmann1
1Gynäklogie und Geburtshilfe der Universität Witten/Herdecke, Marien-Hospital Witten, Witten.
Zeitschrift Fur Geburtshilfe Und Neonatologie
|July 8, 2014
Summary
A standardized partogram is needed in Germany for better birth documentation. This study surveyed healthcare professionals and developed a new model to improve record-keeping and address legal requirements.
Area of Science:
- Obstetrics and Gynecology
- Medical Documentation
- Healthcare Quality Improvement
Background:
- The partogram is a critical document in obstetric practice for midwives and obstetricians.
- Currently, no standardized partogram exists in Germany, posing challenges for legal inquiries.
- This study addresses the need for optimized birth documentation.
Purpose of the Study:
- To explore current requirements for partogram use in Germany.
- To develop a standardized partogram based on identified needs.
- To improve the quality and consistency of birth documentation.
Main Methods:
- A questionnaire was developed based on literature review and expert interviews.
- 95 German hospitals, primarily tertiary referral centers, were randomly selected.
- Obstetricians and midwives were surveyed regarding their partogram practices.
Main Results:
- 51.6% of obstetricians and 25.3% of midwives responded.
- 75% of respondents use a standardized partogram, while others use blank pages or electronic records.
- Variations in cardiotocogram scoring and legal documentation were noted.
Conclusions:
- There is a clear need to optimize current birth documentation practices in Germany.
- A standardized partogram model was developed based on the study's findings.
- The developed partogram aims to enhance consistency and legal security in obstetric records.
Related Concept Videos
01:06Legal Guidelines for Documentation
2.4K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
2.4K
01:20Introduction to Documentation and Reporting
3.3K
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
3.3K
01:23Methods of Documentation V: CBE
1.3K
Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
1.3K
01:29Documentation in Long-Term and Home Healthcare Setting
1.5K
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Long-Term Care Facilities
1.5K
01:30Methods of Documentation VII: EMR
1.5K
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
1.5K
01:26Guidelines for Nursing Documentation II
2.0K
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
2.0K