Year :
2021
| Month :
March
| Volume :
15
| Issue :
3
| Page :
QC09 - QC13
Full Version
A Structured Maternity Case Record to
Improve Quality of Documentation in a
Tertiary Care Hospital, Delhi
Published: March 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/45693.14647
AG Radhika, Chetna Dengri, Abhishek Kumar, Shalini Singh
1. Consultant, Department of Obstetrics and Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
2. Undergraduate Student, Department of Obstetrics and Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
3. Scientist-B, Division of Reproductive Biology Maternal and Child Health, Indian Council of Medical Research, HQRS, V. Ramalingaswami Bhawan, Ansari Nagar,
New Delhi, India.
4. Scientist-F, Division of Reproductive Biology Maternal and Child Health, Indian Council of Medical Research, HQRS, V. Ramalingaswami Bhawan, Ansari Nagar,
New Delhi, India.
Correspondence Address :
AG Radhika,
Consultant, Department of Obstetrics and Gynaecology, 7th Floor, MCH Block,
GTB Hospital, Delhi, India.
E-mail: raradhikaag@gmail.com
Abstract
Introduction: India contributes to about 18% of global maternal deaths and 22.6% of still births. Efforts to improve the quality of care are challenged by the lack of reliable documentation of data. Hence, a concise, structured maternity case sheet (PrasavRecord) was designed with the aim to bring about an improvement in documentation of treatment and events related to woman in labour from the time of admission till her discharge from the hospital.
Aim: To study the improvement in quality of documentation from the time of admission till discharge of a woman in labour with the help of structured format i.e., PrasavRecord.
Materials and Methods: The study was conducted in February 2017. A quasi experimental study design was used, and the completeness of data recorded by the resident doctors in the existing hospital case sheet (control group) with those recorded in PrasavRecord (intervention group) were assessed in a total of 65 deliveries in each arm. Details of the patient from admission to the labour room followed by the entire sequence of events during labour as well as hospital stay in postpartum period were recorded over 130 parameters under different sections in PrasavRecord. Statistical analysis was done by using SPSS version 21.0.
Results: Completeness of the documentation in terms of history, investigations and findings at examination including those at labour, nearly, 92% of the doctors rated PrasavRecord as “good and very good” for appearance, recommended its routine use, and 75% agreed that the format will be useful for conversion to electronic medical record. There was highly significant difference between the average percentage of completeness in PrasavRecord 75.8 {95% CI (74.2-77.4)} and hospital case sheets 42.2 {95% CI (40.9-43.6)} i.e., z=5.38 p-value <0.001.
Conclusion: PrasavRecord is a simple, acceptable and user-friendly data entry format which improves the quality of documentation of the processes and practices during childbirth. Larger trials are required to finetune it to facilitate its widespread use thereby, ensuring a uniform documentation process of labour and postpartum.
Keywords
Childbirth, Hospital case records, Maternity care, Prasav record
DOI: 10.7860/JCDR/2021/45693.14647
Date of Submission: Jun 29, 2020
Date of Peer Review: Jul 23, 2020
Date of Acceptance: Jan 04, 2021
Date of Publishing: Mar 01, 2021
AUTHOR DECLARATION:
• Financial or Other Competing Interests: No
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 30, 2020
• Manual Googling: Jan 04, 2021
• iThenticate Software: Jan 23, 2021 (8%)
ETYMOLOGY: Author Origin
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