Identification of the Application of Midwifery Care Documentation by Midwives in RSUD Pulang Pisau

Midwifery documentation is important because it serves as legal evidence in health care, helping to enforce accountability and liability related to patient care. It also serves as a source of information about the patient's health status and an instrument of protection for patients and midwives. The use of standardized documentation methods such as SOAP has significant benefits in organizing midwives' thought processes, but there are still midwives who have not adopted it. Further efforts are needed to improve understanding and application of documentation standards in midwifery practice. Identifying Integrated Patient Progress Notes by Midwives at Pulang Pisau Regional Hospital in 2023. This study used a descriptive method that describes integrated patient development records by midwives at Pulang Pisau Regional Hospital. The samples in this study were 45 midwives who were in the delivery room, postpartum room and obstetric clinic room. Based on research from 45 midwives, the majority were 21-40 years old, 14 midwives (31.1%) had DIV Midwifery and S1 Midwifery education, 32 midwives (71.1%) had a working period of 6-10 years. 27 respondents (60%) of the completeness of integrated patient progress notes by midwives in the delivery room, postpartum room and obstetric clinic room of Pulang Pisau Hospital were incomplete, and as many as 18 respondents (40%) with complete progress notes. The majority of integrated patient progress notes made by midwives in the labor and delivery room, postpartum room, and obstetric clinic room of Pulang Pisau Regional Hospital were incomplete, with only a small proportion being complete. This suggests the need for improvement in the documentation process and integration of patient progress notes by midwives at RSUD Pulang Pisau.