Completeness of prenatal records in community hospital charts

Abstract

We describe the completeness of prenatal data in maternal delivery records and the prevalence of selected medical conditions and complications among patients delivering at community hospitals around Atlanta, Georgia. Medical charts for 199 maternal-infant dyads (99 infants in normal newborn nurseries and 104 infants in newborn intensive care nurseries) were identified by medical records staff at 9 hospitals and abstracted on site. Ninety-eight percent of hospital charts included prenatal records, but over 20 percent were missing results for common laboratory tests and prenatal procedures. Forty-nine percent of women had a pre-existing medical condition, 64 percent had a prenatal complication, and 63 percent had a labor or delivery complication. Missing prenatal information limits the usefulness of these records for research and may result in unnecessary tests or procedures or inappropriate medical care.