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Permanent link (DOI): https://doi.org/10.7939/R3610W038

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

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Author or creator
McDonald, S. D.
Machold, C. A.
Marshall, L.
Kingston, D.
Additional contributors
Subject/Keyword
documentation
obesity
prenatal care
guideline adherence
antenatal medical records
Type of item
Journal Article (Published)
Language
English
Place
Time
Description
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.
Date created
2014
DOI
doi:10.7939/R3610W038
License information
Creative Commons Attribution-Non-Commercial 3.0 Unported
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Citation for previous publication
McDonald, S. D., Machold, C. A., Marshall, L., & Kingston, D. (2014). Documentation of guideline adherence in antenatal records across maternal weight categories: a chart review. BMC Pregnancy and Childbirth, 14(1).
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