ASSESSING THE COMPLETENESS OF PATIENT MEDICAL RECORDS OF OBSTETRIC PATIENTS IN THE PUHMS TERTIARY CARE CENTER.
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Abstract
BACKGROUND: Incomplete medical records can compromise patient safety and care quality. This assessment evaluates the completeness of obstetric patients' records to identify documentation gaps and their impact on maternal and fetal outcomes.
OBJECTIVE: The objective of our study is to Asses the completeness of patient medical records of obstetric patients in PUHMS tertiary care center.
METHODOLOGY:
DESIGN: Descriptive Cross-sectional.
SETTING: IMCH PUMHS, Obstetrics & Gynecology Ward, Unit II.
SAMPLING TECHNIQUE: Non-probability consecutive sampling.
DURATION: FROM 06-11-2023 TO 05-05-24.
METHOD: The study assessed the completeness of antenatal medical records at People's University of Medical and Health Sciences (PUHMS) by reviewing 100 patient files. The documentation sheets analyzed included admission, history, examination, progress notes, nursing notes, vital signs, procedures, and clinical pharmaceutical records. The sample reflected a diverse range of antenatal patients from both low- and high-risk categories. Each sheet was evaluated for completeness using descriptive statistics and frequency distributions, with findings visually represented.
RESULT: Documentation completeness varied widely across the following sheets: Admission (28%), History (53%), Examination (66%), Nursing (71%), Vital Signs (48%), Procedure (59%), and Clinical Pharmaceutical (68%). Incomplete documentation, particularly on admission and vital signs sheets (48%), correlated with adverse fetal outcomes like prolonged labor, preeclampsia, and neonatal distress. Well-documented cases (93% maternal and 89% fetal favorable outcomes) emphasized the importance of thorough documentation in facilitating timely interventions and improving health outcomes.
Conclusion: The data strongly suggests that incomplete antenatal records compromise care continuity, delay diagnosis, and adversely impact both maternal and fetal outcomes. Key documentation gaps, especially in admission, vital signs, and pharmaceutical records, directly correlate with higher rates of NICU admissions, stillbirths, and maternal infections or death.
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Sumera
PG Trainee, PUMHS, Sumeramemo789@Gmail.Com
Badarunisa
MBBS, FCPS, PUMHS Dr.Badarunisa@Yahoo.Com
Sobia
WMO, DGO, PUMHS Drsobiayakhan184@Gmail.Com
Nissa
MBBS, Senior WMO, Maternity Home Rohri, Dr.Nissamemon@Gmail.Com
Saima Chandio
M.S, PUMHS Saimahussainwagan1@Gmail.Com
Raishem
FCPS, Associate Professor, PUMHS, Aliresham987@Gmail.Com