What happens at the postpartum visit? Discordance between patient-reported and electronic medical record-documented...

To examine discordance between postpartum care reported by patients and documentation in the electronic medical record (EMR).

We analyzed data from a randomized controlled trial of pregnant patients with cardiometabolic risk factors (n = 282). Concordance between self-report and EMR documentation was assessed for outpatient postpartum visits within 12 weeks and selected elements (mood disorder screening, diabetes testing, counseling). We fit multivariable log binomial models to estimate risk ratios (RR) and 95% confidence intervals (CI) for the association between age, parity, and discordant reporting, adjusting for intervention assignment.

Overall, 74.7% of participants had concordant documentation of a postpartum visit between self-report and EMR, 20.5% had care documented on only one (19.7% EMR only, 0.8% self-report only), and 4.8% concordant documentation of no care. Participants > 34 years were half as likely to have discordant report of a visit compared to participants ages 20-34 (RR: 0.4, 95% CI: 0.2, 0.9). Primiparous participants were slightly less likely than multiparous participants to have discordant reporting (RR: 0.7 (0.4, 1.2)). Patterns were similar for diabetes testing, mood screening, and cardiovascular risk counseling, though documentation was less common (1.1%, 62.7%, 31.6% concordant).

We found disagreement between self-report and EMR-documentation of postpartum care.