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Using chart reviews to assess postpartum substance abuse. A pilot study
Lorraine T Midanik1, Mary Anne Armstrong, Leslie Lieberman
1School of Social Welfare, University of California at Berkeley, 120 Haviland Hall 7400, Berkeley, CA 94720-7400, USA. lmidanik@uclink4.berkeley.edu
Social Work in Health Care
|May 20, 2004
Summary
This pilot study found that postpartum substance use information is often missing from medical charts. Interviews are crucial for accurate assessment, as provider documentation is inadequate for alcohol, drug, and tobacco use.
Area of Science:
- Obstetrics and Gynecology
- Public Health
- Addiction Medicine
Background:
- Postpartum care requires comprehensive assessment of maternal health, including substance use.
- Inadequate documentation of substance use can lead to missed opportunities for intervention.
- Previous research indicates a gap in routine screening for substance use in postpartum women.
Purpose of the Study:
- To evaluate the utility of chart reviews in assessing one-year postpartum substance use.
- To compare the accuracy of chart reviews against patient interviews for substance use data.
- To identify deficits in provider documentation regarding postpartum substance use.
Main Methods:
- A pilot study involving 23 women with identified pregnancy risk factors.
- Comparison of data from patient interviews with medical chart reviews one year postpartum.
- Analysis of documentation for alcohol, drug, and tobacco use.
Main Results:
- Chart reviews indicated that providers did not inquire about alcohol use in 83% of cases.
- Drug use was not documented in 57% of charts, and tobacco use in 26%.
- Few matches were found between interview data and chart reviews due to general underreporting of substance use.
Conclusions:
- Interviews are essential for obtaining accurate postpartum substance use information.
- Current chart review practices are insufficient for assessing postpartum substance use.
- Healthcare providers may need enhanced training and protocols for addressing maternal substance use.