Postpartum Note Template Implementation Demonstrates Adherence to Recommended Counseling Guidelines.

Abstract

Postpartum visits may provide patients with an inadequate amount of counseling on postpartum depression, birth spacing, healthy eating, exercise, or changes in sexual response and emotions. We created a template in our electronic health record (EHR) with the aid of our clinical informatics department to increased adherence with recommended counseling guidelines. We retrospectively reviewed the postpartum visits of 200 patients who had a delivery and received postpartum care. Patients were seen in a resident-run clinic: 100 visits occurred prior to implementation of the template, while 100 visits occurred post-implementation with use of the template. We observed for documentation of counseling on Pap smear, birth spacing, breastfeeding, contraception, depression, gestational diabetes mellitus, pre-eclampsia, and sleep/fatigue. Descriptive statistics of mean and standard deviation were used to describe the continuous variables. Frequency and percentage were used to describe the continuous variables. Analysis of variance compared the continuous variables. The Pearson chi-square test compared the categorical variables. In visits that occurred without use of the template, counseling was charted as low as 1.0% for birth spacing to as high as 86.0% for contraception. With use of the template, counseling was charted as 100% in all visits for each of the recommended counseling guidelines (all p < 0.001). In conclusion, an EHR template for documentation of postpartum visits is associated with resident adherence with recommended postpartum counseling guidelines. Managers in hospitals and clinical practices should consider incorporating OBGYN-specific EHR note templates to improve quality and increase adherence with recommended guidelines during postpartum visits.