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

BMC Pregnancy and Childbirth

Dawn Kingston³  Laura Marshall²  Clea A Machold⁴  Sarah D McDonald¹ 

[1]Division of Maternal-Fetal Medicine, Departments of Obstetrics & Gynecology and Diagnostic Imaging and Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main St. West, HSC 3N52B, Hamilton, ON L8S4K1, Canada

[2]Faculty of Health Sciences, Department of Obstetrics, Gynecology1280 Main St. West, HSC 3 N52, Hamilton, ON L8S4K1, Canada

[3]Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9, Canada

[4]Department of Obstetrics, Gynecology1280 Main St. West, HSC 3 N52, Hamilton, ON L8S4K1, Canada

关键词: Prenatal care;    Obesity;    Guideline adherence;    Documentation;    Antenatal medical records;   

Others  :  1127205
DOI  :  10.1186/1471-2393-14-205

 received in 2013-11-28, accepted in 2014-05-28,  发布年份 2014

【 摘 要 】

Background

Documentation 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.

Methods

We 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.

Results

The 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.

Conclusion

Despite 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.

【 授权许可】

   
2014 McDonald et al.; licensee BioMed Central Ltd.

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