Assessing the Completeness of Patient Medical Records of Obstetric Patients in the PUHMS Tertiary Care Center

Abstract

Background: Quality maternal care, early risk identification and prevention of complications require accurate and complete obstetric documentation. In spite of the global advancements, documentation practices in low-resource settings are not consistent. Objective: To determine the fullness of the obstetric medical records in Peoples University of Medical and Health Sciences (PUHMS) and test the correlation between the under completeness of the documentation and the complications of either the mother or fetus, specifically, high-risk pregnancy. Methods: The study was a cross-sectional descriptive study carried out in the Department of Obstetrics and Gynecology, Unit-II, PUHMS, 24 May 2024 to 23 November 2024. A random sample of one hundred inpatient obstetric files was picked and reviewed with the help of a structured checklist of eight record sections. The SPSS v25 was used to compare data using descriptive statistics and Chi-square at p<0.05. Results: Section completeness was also significantly different, with admission (28%), vital signs (48%), history (53%), examination and progress notes (66%), nursing (71%), procedure (59%), and pharmaceutical (68%). In 7 percent, maternal complications and 11 percent, fetal adverse events including mostly surgical-site infection and NICU admissions happened. Clinical association came with higher complication rates associated with incomplete documentation, but was not statistically significant due to the sample size. Conclusion: There are big documentation loopholes especially in admission and vital-sign sheets which can make it difficult to identify high-risk cases like placenta accreta spectrum. Standardized forms, staff training and electronic systems can strengthen record keeping to enhance maternal safety and inform health policy and educational interventions.

Obstetric record, maternal outcome, completeness of record, high risk pregnancy, PUHMS, placenta accreta spectrum, Pakistan.