Completeness of data record in the obstetric record form

Abstract

Objective: To survey the completeness of obstetric data records. Material and Method: A survey study was conducted to determine the completeness of obstetric data records of women who delivered at Songklanagarind Hospital from January 1, to June 30, 2012 in the obstetric data record forms of the Statistical Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University. The data consisted of 5 parts including general information, obstetric history, pregnancy outcome, complications and operative obstetrics with indications. Rates of completeness by recorders were calculated. Results: A total of 1,698 obstetric data records were evaluated. The overall rate of completeness was 10.1%. The rates of completeness of the general information (part 1), recorded by nurses, and the clinical part (parts 2 to 5), recorded by physicians, were 36.7% and 26.1%. The intern had the highest rate of completeness, followed by the extern and the resident. Conclusion: The rate of completeness of obstetric data records was low. The feedback report will be sent to the Department of Obstetrics and Gynecology to find out an appropriate strategy to improve quality of electronic database for future use in research and quality service management.

Keywords

• completeness
• data
• obstetric patient
• record