2015 Prenatal MediSource Medical Record Review Results

2015 Prenatal MediSource Medical Record Review Results

The Clinical Quality Department performed a medical record review to ensure that practitioners are documenting in accordance with Independent Health medical record criteria and the NYS Department of Health (NYSDOH) requirements.

A quality review of 195 random sample prenatal MediSource records was performed in August 2015. The review consisted of members that had a live birth in 2014. This annual audit is a comprehensive review following American College of Obstetrics and Gynecologists (ACOG) Prenatal Guidelines and NYSDOH best practice standards.

The overall results are presented in the table below, along with the 2014 results to be used as a comparison. HIV testing and nutrition assessment were added in 2015.

*Not applicable due to eligibility requirements or patient refusal.
Medical Record Review Component 2015
% Documented
% N/A*
% Documented
% N/A*
Oral Health 18 23
Pre-pregnancy BMI 30 20
Influenza Administration (Sept.-Feb.) 27 29 29 10
Tdap Administration (27-36 weeks) 20 1 20
TB Assessment 83 32
TB Testing (if indicated) 4 78 2 28
Tobacco Use Assessment 99 100
Documentation of Referrals 50 55
Post-partum Visit 58 73
HIV Testing 93
Nutrition Assessment 59

Seventy-six percent of the records reviewed were electronic medical records (EMR) and 24 percent of the records reviewed were handwritten or typed using ACOG forms. This type of record enables practitioners to obtain a more comprehensive health assessment of the patient by utilizing prompts that incorporate clinical practice guidelines, clinical health alerts and reminders. Many EMRs already have the necessary prompts to meet the required documentation as indicated above but are not being completed. Those that do not have the necessary prompts for the required documentation can have them updated and incorporated into the EMR by working with their respective IT departments or EMR vendors. The handwritten and/or typed records were difficult to read and lacked detailed assessment and documentation of the education provided.

Those that are still using ACOG forms that are handwritten or typed are severely limited in incorporating the required documentation for a comprehensive health assessment and education provided due to not having a flexible format or space.

Based on the above results, there are many opportunities for improvement for documentation in a prenatal record, including:

  • Oral Health – An assessment of the woman’s oral health care needs should be performed at the first prenatal visit. The assessment should include interviewing the patient regarding current oral health problems, previous dental problems and the availability of a dental provider. If an oral health problem is identified and/or the patient has not had a dentist visit in the past six months, the patient should be referred to a dentist.
  • Pre-pregnancy BMI – A pre-pregnancy weight is always documented in the record; however, a pre-pregnancy BMI should also be documented according to ACOG guidelines.
  • Influenza Immunization – This should be strongly recommended for all pregnant women, especially those with a chronic condition such as asthma or diabetes, or a history of smoking. It should be administered during a prenatal visit occurring between September and February.
  • Tdap Immunization – This should be administered with every pregnancy regardless of the patient’s prior history of receiving Tdap or Td. This recommendation was published in 2013 and was supported by ACOG.

Immunizations should be administered in the OB office eliminating the need for an additional office visit with a primary care physician, which may be a barrier for some patients.

  • Tuberculosis – All prenatal patients should be assessed for TB. According to the Centers for Disease Control and Prevention, untreated TB represents a greater hazard to a pregnant woman and her fetus than does its treatment. Treatment should be initiated whenever the probability of TB is moderate to high. Infants born to women with untreated TB may have a lower birth weight than those born to women without TB. In rare circumstances, the infant may also be born with TB. Although the drugs used in the initial treatment regimen for TB cross the placenta, they do not appear to have harmful effects on the fetus. More information can be found at www.cdc.gov/tb/publications/factsheets/specpop/pregnancy.htm.
  • Tobacco Use Assessment – Patients are being assessed for tobacco use. For those that report smoking, there rarely is documentation that the patient was counseled regarding cessation and/or continuous assessment of their status with cessation. All patients (not just Independent Health members) are eligible for the Baby and Me Smoke Free program, which is offered through the Independent Health Foundation.
  • Referrals – Documentation in the record should reflect all referrals, including WIC, smoking cessation, behavioral health, cardiology, endocrinology, social programs and case management to facilitate and improve coordination of care.
  • Post-partum visits – Patients should be scheduled for a postpartum visit 4-6 weeks after delivery. The visit should include how the baby is being incorporated into the family, and a complete patient assessment for postpartum depression (PPD). A suture check or removal of sutures one week post C-section does not count as a postpartum visit.
  • HIV testing – Testing is being completed 93 percent at least once during prenatal care.
  • Nutrition Assessment – A thorough nutrition assessment should be completed. Documentation of the patient’s normal daily diet should be included in the assessment. High risk patients such as underweight and/or overweight obese or diabetic should be referred for counseling.