Abstract
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.
Highlights
Documentation in medical records fulfills key functions, including management of care, communication, quality assurance and record keeping
With regards to outcomes related to standard prenatal care, we examined the documentation of the following components in the antenatal record: i. maternal screening: pre-pregnancy weight, height and body mass index (BMI) calculation, weight at subsequent visits, Papanicolaou test, gonorrhea and chlamydia tests, and gestational diabetes, and Group Beta Streptococcus (GBS) status; ii. prenatal genetic screening: the Integrated Prenatal Screen (IPS), First Trimester Screening (FTS) or Maternal Serum Screening (MSS) or chorionic villus sampling or amniocentesis, and first trimester [14] and second trimester ultrasound scans, and iii. counseling and education on 21 ‘discussion topics’ addressing subjects such as exercise, fetal movement, preterm labour, prenatal classes, birth plans, pain management, and breastfeeding
With regards to outcomes related to prenatal care specific to obese women, we examined the following components of documentation in the Antenatal Record of the prenatal care portion of the obesity guidelines [13]: i. body mass index (BMI) - calculated from pre-pregnancy height and weight; ii. counseling about weight gain, nutrition, and food choices; iii. counseling about increased risk of congenital abnormalities, and appropriate screening; iv. counseling about increased risk for medical complications and that regular exercise during pregnancy may help to reduce some of these risks
Summary
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. The increased risk of complications in obese women is concerning as outside of pregnancy obese women have been found to be less likely to seek or receive key elements of health care including screening [8,9,10]. We sought to determine documentation of adherence to recommendations for standard prenatal care for women across all weight classes, and given the higher perinatal risks in women of excess weight, whether this documentation varied among normal weight, overweight and obese women. In the case of obese women, was to determine the degree of documented adherence to obesity guidelines [12,13]
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