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Related Experiment Videos

Variations in compliance with documentation using computerized obstetric records.

Shoshana Haberman1, Michael Rotas, Katerina Perlman

  • 1Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York 11219, USA. shelhaber@aol.com

Obstetrics and Gynecology
|July 3, 2007
PubMed
Summary
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Documentation completeness in electronic medical records (EMR) significantly decreases when automated reminders are deactivated. Provider type and clinical factors impact completeness, highlighting areas for improved obstetrical record-keeping.

Area of Science:

  • Obstetrics and Gynecology
  • Health Informatics
  • Medical Documentation

Background:

  • Electronic medical records (EMR) with decision support systems (DSS) are crucial for modern healthcare.
  • Optimizing documentation completeness in EMR is essential for patient care and research.
  • The impact of DSS features, like reminders, on documentation completeness is not fully understood.

Purpose of the Study:

  • To investigate factors influencing documentation completeness within an obstetrical EMR system.
  • To assess the effect of deactivating repetitive prompts on documentation quality.

Main Methods:

  • Analysis of 2,809 deliveries using structured EMR data.
  • Customization of DSS to deactivate specific documentation completeness reminders.

Related Experiment Videos

  • Outcome variables: completeness of estimated fetal weight, pelvic adequacy, and fetal position documentation.
  • Statistical analysis using general linear univariable models and Tukey's honest difference method.

    • Main Results:

    • Midwives demonstrated higher documentation completeness (fewer missing items) compared to attending and resident physicians.
    • Significant differences in completeness were observed between vaginal birth after cesarean and repeat cesarean deliveries.
    • Neonatal intensive care unit admissions showed lower documentation completeness than regular nursery admissions.
    • Patients with unclassified labor status had significantly less complete documentation.

    Conclusions:

    • EMR documentation compliance is notably low when automated reminders are disabled.
    • Documentation completeness varies significantly based on healthcare provider type.
    • Clinical patient factors, such as labor classification and delivery type, influence documentation completeness.