Prenatal records: A national survey of content

Peoples-Sheps, Mary D.; Kalsbeek, William D.; Siegel, Earl; Dewees, Cornelia; Rogers, Mary Moussa; Schwartz, Robert

doi:10.1016/s0002-9378(11)80011-6

Cited by 20 publications

(19 citation statements)

References 3 publications

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“…Documentation in prenatal records fulfills key functions, including patient care management, communication, quality assurance and record keeping for legal purposes [24]. We found suboptimal documentation in many areas of prenatal care and the observed rates of documentation did not increase across weight categories despite both increasing perinatal risks, and guidelines specifically addressing recommendations related to weight in obese women [12,13].…”

Section: Discussionmentioning

confidence: 99%

Documentation of guideline adherence in antenatal records across maternal weight categories: a chart review

McDonald

Machold

Marshall

et al. 2014

BMC Pregnancy Childbirth

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BackgroundDocumentation in medical records fulfills key functions, including management of care, communication, quality assurance and record keeping. We sought to describe: 1) rates of standard prenatal care as documented in medical charts, and given the higher risks with excess weight, whether this documentation varied among normal weight, overweight and obese women; and 2) adherence to obesity guidelines for obese women as documented in the chart.MethodsWe conducted a chart review of 300 consecutive charts of women who delivered a live singleton at an academic tertiary centre from January to March 2012, computing Analysis of Variance and Chi Square tests.ResultsThe proportion of completed fields on the mandatory antenatal forms varied from 100% (maternal age) to 52.7% (pre-pregnancy body mass index). Generally, documentation of care was similar across all weight categories for maternal and prenatal genetic screening tests, ranging from 54.0% (documentation of gonorrhea/chlamydia tests) to 85.0% (documentation of anatomy scan). Documentation of education topics varied widely, from fetal movement in almost all charts across all weight categories but discussion of preterm labour in only 20.6%, 12.7% and 13.4% of normal weight, overweight and obese women’s charts (p = 0.224). Across all weight categories, documentation of discussion of exercise, breastfeeding and pain management occurred in less than a fifth of charts.ConclusionDespite a predominance of excess weight in our region, as well as increasing perinatal risks with increasing maternal weight, weight-related issues and other elements of prenatal care were suboptimally documented across all maternal weight categories, despite an obesity guideline.

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Section: Discussionmentioning

confidence: 99%

Documentation of guideline adherence in antenatal records across maternal weight categories: a chart review

McDonald

Machold

Marshall

et al. 2014

BMC Pregnancy Childbirth

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“…To truly serve these purposes, documentation must be complete, accurate, and collected systematically. Recognizing that systematic, detailed recordkeeping can improve quality of care and that the use of standard forms can improve recordkeeping, 27 ACOG and other organizations have produced forms to facilitate documentation of prenatal and delivery services. Such forms were included in only a few of the records we examined.…”

Section: Documentationmentioning

confidence: 99%

Assessment of Screening, Treatment, and Prevention of Perinatal Infections in the Philadelphia Birth Cohort

Jessop¹,

Watson

Mazar

et al. 2005

Am J Med Qual

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Certain population groups are at risk for inadequate prenatal care and transmission of perinatal infections. Philadelphia's birth cohort comprises largely at-risk groups and its infant mortality rate is among the nation's highest. This study identifies factors associated with infectious disease screening, treatment, and prevention in Philadelphia. Delivery charts for a probability sample of 550 patients were reviewed. Demographic factors associated with prenatal and delivery care were identified through Pearson chi-square, analysis of variance, and stepwise logistic regression analysis. Nonstandard and incomplete documentation complicated abstraction. Some prenatal care was noted in 95% of the records and screening varied by disease. Factors independently associated with care include maternal race, insurance status, and maternal age. Screening for infections with well-established recommendations (hepatitis B virus, rubella, syphilis) occurred more often than for group B streptococcus, HIV, hepatitis C virus, and varicella. Adoption of standard reporting forms and processes could improve practice and aid in quality improvement efforts and patient communication.

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“…The findings that there are variations in the content of prenatal care by predictors of preterm delivery (age, ethnicity, etc.) We collected data from written forms and protocols, something previously suggested [33]. The importance of including quality of care parameters in examining the adequacy of prenatal care is clear, as seen in the fact that many women receive prenatal care far below minimal standards of quality [31 ], and that women who report receiving sufficient health behavior advice as part of their prenatal care are at lower risk of delivering a low-birth-weight infant [32].…”

Section: Discussionmentioning

confidence: 99%

Prenatal care and prevention of preterm birth

et al. 1996

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The value of prenatal care is controversial and difficult to establish. A national policy for improving perinatal outcomes was proposed and applied throughout Andalusia (Southern Spain) in 1984. Here we report the results of an evaluation of this health care program as regards the prevention of preterm delivery. Effectiveness of prenatal care was assessed on the basis of two case-control studies in a hospital setting: one performed before the program was implemented (1981-1982) and the second one six years after the program began (1990-1993). A total of 229 cases and 395 controls for the period 1981-1982, and 207 cases and 381 controls for 1990-1993 were selected. Prenatal care was assessed based on the number of prenatal care visits, the date of the first visit, and an American composite index adjusting for gestational age. Multiple-factor adjusted odds ratios and their 95% confidence intervals (CI) were estimated using unconditional logistic regression analysis. The use of prenatal care significantly improved across time: the proportion of women receiving no prenatal care decreased from over 30% to less than 5%, and the proportion of women starting prenatal care in the first trimester for 1990-1993 was three times greater than the figure for 1981-1982. In the 1981-1982 case-control study, the date of first visit and the composite index were shown to be unrelated to preterm birth risk; and the number of visits yielded a significant association, although no definite trend could be established. In the 1990-1993 case-control study, a clear and significant relationship was observed between the number of prenatal care visits, the trimester of the first visit, and the adequacy of care according to the composite index. This latter variable, reflecting a more stringent standard of prenatal care, was selected by a stepwise logistic regression analysis as the best predictor for preterm birth risk. The results suggest that the present Andalusian program helps prevent preterm delivery. Nonetheless, its minimum standards should be raised to further decrease preterm birth risk.

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Prenatal records: A national survey of content

Cited by 20 publications

References 3 publications

Documentation of guideline adherence in antenatal records across maternal weight categories: a chart review

Documentation of guideline adherence in antenatal records across maternal weight categories: a chart review

Assessment of Screening, Treatment, and Prevention of Perinatal Infections in the Philadelphia Birth Cohort

Prenatal care and prevention of preterm birth

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