Adoption and Completeness of Documentation Using a Structured Delivery Record in Secondary Care, Subdistrict Government Hospitals of Karnataka State, India

Authors : Mony PK, Jayanna K, Varghese B, Washington M, Vinotha P, Thomas T

Publication Year : 2016

Abstract :


Poor medical record documentation remains a pervasive problem in hospital delivery rooms, hampering efforts aimed at improving the quality of maternal and neonatal care in resource-limited settings. We evaluated the feasibility and completeness of labor room documentation within a quasi-experimental study aimed at improving emergency preparedness for obstetric and neonatal emergencies in 8 nonteaching, subdistrict, secondary care hospitals of Karnataka state, India.


We redesigned the existing open-ended case sheet into a structured, delivery record cum job aide adhering to principles of local clinical relevance, parsimony, and computerizability. Skills and emergency drills training along with supportive supervision were introduced in 4 “intervention arm” hospitals while the new delivery records were used in eight intervention and control hospitals.


Introduction of the new delivery record was feasible over a “run-in” period of 4 months. About 92% (6103 of 6634) of women in intervention facilities and 80% (6205 of 7756) in control facilities had their delivery records filled in during the 1-year study period. Completeness of delivery record documentation fell into one of two subsets with one set of parameters being documented with minimal inputs (in both intervention and control sites) and another set of parameters requiring more intensive training efforts (and seen more in intervention than in control sites; P < .05).


Under the stewardship of the local government, it was possible to institute a robust, reliable, and valid medical record documentation system as part of efforts to improve intrapartum and postpartum maternal and newborn care in hospitals.