Abstract
Objective To study the impact of a prenatal electronic medical record (EMR) on the adequacy
of documentation.
Study Design The authors reviewed paper prenatal records (historical control arm and contemporaneous
control arm), and prenatal EMRs (study arm). A prenatal quality index (PQI) was developed
to assess adequacy of documentation; the prenatal record was assigned a score (range,
−1 to 2 for each element, maximum score = 30). A PQI raw score and PQI ratio—that
controlled for which elements of care were indicated for a patient—were calculated
and compared between the study arm versus historical control arm and then the study
arm versus contemporaneous control arm.
Results The median PQI raw score was significantly lower in the study arm compared with historical
control arm; however, the PQI ratios were similar between these groups. The PQI raw
score was similar in both the study arm and contemporaneous control arm; however the
PQI ratio was significantly higher in the study arm when compared with the contemporaneous
control arm.
Conclusion Implementation of this prenatal EMR did not have a significant impact on completeness
of documentation when compared with a standardized paper prenatal record. Adequacy
of documentation seems to be related to the type of practice.
Keywords
electronic medical record - prenatal care - outpatient clinic
