Prenatal records: a national survey of content

Prenatal records serve several functions in addition to facilitating prenatal care for individual patients: they also enable communication among health care providers, allow monitoring of quality assurance, provide legal documentation, and establish a basis for financial compensation. The records should be problem-oriented, systematic, and detailed. To evaluate the extent to which maternity records actually meet these standards, 940 randomly selected physicians (90 percent were obstetricians, gynecologists, or specialists in maternal-fetal medicine) and 29 doctors of osteopathy were studied. They were asked to send blank copies of the prenatal records used and to complete questionnaires concerning practice and demographic data. Respondents represented 38 percent of an original group of 2,746 who were asked to participate. The records were evaluated to determine the inclusion of 53 specific items relevant to the pregnant patient; background data, especially socioeconomic; medical and obstetrical history; initial pregnancy surveillance; patient education; complications; risk factors; laboratory tests; other diagnostic procedures; and therapeutic procedures. Ten factors, present in between 11 percent and 89 percent of the records, were selected for more extensive analysis. Results showed that almost half the respondents used prenatal records that were not commercial forms. In more than 90 percent of the cases, traditional medical-obstetric items were included in the records, such as the date of the last menstrual period or a history of previous pregnancies. However, a much smaller proportion (fewer than 10 percent, for some items) contained information about factors recognized as significant in recent years. These included psychological stress, smoking habits, or risk factors. These items were usually included on commercial forms. Physicians who included them tended to practice in hospital- or government-based settings, and to have been in practice for 15 or fewer years. The results show that the detailed prenatal records needed for a variety of purposes other than are not commonly used by physicians. (Consumer Summary produced by Reliance Medical Information, Inc.)