Using a prenatal electronic medical record to improve documentation within an inner-city healthcare network

Area of Science:

• Obstetrics and Gynecology
• Health Informatics
• Medical Documentation Quality

Background:

• Adequate prenatal documentation is crucial for patient care quality.
• Electronic Medical Records (EMRs) are increasingly adopted in healthcare settings.
• The impact of prenatal EMRs on documentation completeness requires evaluation.

Purpose of the Study:

• To assess the effect of a prenatal electronic medical record (EMR) system on the adequacy of prenatal record documentation.
• To compare documentation quality between EMRs and traditional paper-based prenatal records.

Main Methods:

• A prenatal quality index (PQI) was developed to quantify documentation adequacy.
• Paper prenatal records (historical and contemporaneous controls) and prenatal EMRs (study arm) were reviewed.
• PQI raw scores and PQI ratios were calculated and compared between study and control groups.

Main Results:

• The median PQI raw score was lower in the EMR group compared to the historical paper records, but PQI ratios were similar.
• PQI raw scores were comparable between the EMR and contemporaneous paper records.
• The PQI ratio was significantly higher in the EMR group compared to the contemporaneous paper records.

Conclusions:

• This prenatal EMR implementation did not significantly enhance documentation completeness versus standardized paper records.
• The adequacy of prenatal documentation may be more closely associated with the specific practice environment than the record format.