Prenatal records: a national survey of content

The uses of prenatal records extend well beyond management of patient care. They are also vehicles for communication, quality assurance, financial compensation, and legal documentation. To serve each of these functions, records should be systematic and detailed. This nationwide study was conducted to assess the extent to which prenatal records in current use include sufficient detail to serve these functions. A random sample of 2746 physicians who listed obstetrics and gynecology, obstetrics, or maternal-fetal medicine as a primary or secondary specialty in the American Medical Association file were contacted by mail and were requested to submit a blank copy of their prenatal records. The records of 969 respondents were examined for the presence or absence of 53 items that corresponded to the five functions identified above. The items of interest were present in 1% to 98% of the records. More than 90% included items of traditional medical-obstetric significance. The percentages of records with items of more contemporary relevance (e.g., cigarette smoking, risk-assessment checklists, psychological stress) were found in lower percentages of the records. Stratified and logistic regression analyses revealed that the most systematic and detailed records were commercially available, were used by physicians in hospital and government program-based practices, and were used by physicians who had completed medical school less than or equal to 15 years before the survey. The findings suggest that physicians who do not use commercially available forms or those who are in private or health maintenance organization practice or have been practicing for more than 15 years should reconsider their prenatal records in light of the functions they will serve in the 1990s and beyond.