title: Using a prenatal electronic medical record to improve documentation within an inner-city healthcare network.
abstract: OBJECTIVE
  To study the impact of a prenatal electronic medical record (EMR) on the adequacy of documentation.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Jeny
authors.initials: J
authors.lastname: Ghartey
authors.affiliation: Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Colleen
authors.initials: C
authors.lastname: Lee
authors.affiliation: Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Elisheva
authors.initials: E
authors.lastname: Weinberger
authors.affiliation: Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Nathan
authors.affiliation: Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Irwin R
authors.initials: IR
authors.lastname: Merkatz
authors.affiliation: Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Peter S
authors.initials: PS
authors.lastname: Bernstein
mesh_terms: D000328:Adult; D004282:Documentation / Q000592:standards*; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D011247:Pregnancy; D011295:Prenatal Care; D058996:Quality Improvement; D019037:Urban Health Services / Q000458:organization & administration*; D055815:Young Adult