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.
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