Preconception health risk factors documented in general practice electronic medical records

Documenting medical and lifestyle preconception health risk factors in electronic medical records (EMRs) could assist general practitioners (GPs) to identify those reproductive-aged women who could most benefit from preconception care (PCC). However, it is unclear to what extent PCC risk factors are identifiable in general practice records. This study aimed to determine the extent to which medical and lifestyle preconception health risk factors are documented in general practice EMRs.

We conducted an audit of the documentation of medical and lifestyle preconception risk factors in 10 general practice EMRs in Melbourne, Australia. We retrospectively analysed the EMRs of 100 consecutive women aged 18-44 years who visited each practice between January and September 2022. Using a template informed by PCC guidelines, we extracted data from structured fields in the EMR and conducted a descriptive analysis.

Among the data extracted, the more commonly documented medical and lifestyle preconception health risk factors in the EMRs included smoking (79%), blood pressure (74%), alcohol consumption (63%) and body mass index (57%). Among the women audited, 14% were smokers, 24% were obese, 7% had high blood pressure, 5% had diabetes, 28% had a mental health condition, 13% had asthma, 6% had thyroid disease and 17% had been prescribed and could be using a potentially teratogenic medication.

Better documentation of medical and lifestyle preconception health risk factors in structured fields in EMRs may potentially assist primary care providers including GPs in identifying and providing PCC to women who could most benefit from it.