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[Information recorded by maternity ward staff in permanent pediatric health records]
M Chalumeau1, R Assathiany, C Francoual
1Inserm U 149, recherches épidémiologiques sur la santé périnatale et la santé des femmes, 123, boulevard de Port-Royal, 75014 Paris, France. martin.chalumeau@wanadoo.fr
Insights
Maternity ward staff generally complete pediatric health records well, but some crucial data like sensorial screening are underreported. New information on pregnancy and delivery is desired by pediatricians.
Area of Science:
- Pediatric Health Records
- Perinatal Data Collection
- Medical Record Keeping
Context:
- Assessing the completeness of perinatal information in infant health records is crucial for continuity of care.
- Maternity ward staff play a key role in documenting essential perinatal data.
- Pediatric health records serve as a permanent documentation of a child's health journey.
Purpose:
- To evaluate the frequency of completion for perinatal information in pediatric health records.
- To identify specific data points that are frequently omitted or underreported.
- To gather insights from pediatricians on desired perinatal information.
Summary:
- An observational study analyzed 1,785 pediatric health records to assess perinatal information completeness.
- Completion rates varied significantly, with some vital items like response to stimuli rarely documented.
- Pediatricians expressed a need for more data on vertical infection risk factors.
Impact:
- Highlights the need for improved documentation of critical perinatal data, such as sensorial screening.
- Suggests optimizing pediatric health records by removing obsolete items and incorporating new, relevant information.
- Informs strategies for enhancing perinatal data collection to support better pediatric care.
Objectives:
To study the frequency with which maternity ward staff complete the perinatal information section of infants' permanent pediatric health records.
Methods:
In 2000, 71 pediatricians in private practice and on staff in a general pediatric ward in a tertiary hospital in Paris carried out an observational study to assess which indicators were reported at what rates. Pediatricians were also asked which information about the perinatal admission they would find helpful in these records.
Results:
One thousand seven hundred and eighty-five pediatric health records were studied. The frequency of completed information varied from 5 to 100%, depending on the item. Of the items reported rarely, some, such as thoracic circumference, were obsolete, while others were very important (response to noise, light reflex). The new information desired by office-based pediatricians involved mainly risk factors for vertical infections (maternal fever during delivery, prolonged rupture of the membranes).
Conclusion:
Although the rate of completion of information in the pediatric health record was globally good, some important data should be reported more often (sensorial screening), while other items could be deleted. New information about the pregnancy and delivery would be useful.