title: Documentation of guideline adherence in antenatal records across maternal weight categories: a chart review.
abstract: BACKGROUND
  Documentation in medical records fulfills key functions, including management of care, communication, quality assurance and record keeping. We sought to describe: 1) rates of standard prenatal care as documented in medical charts, and given the higher risks with excess weight, whether this documentation varied among normal weight, overweight and obese women; and 2) adherence to obesity guidelines for obese women as documented in the chart.
  
  
  METHODS
  We conducted a chart review of 300 consecutive charts of women who delivered a live singleton at an academic tertiary centre from January to March 2012, computing Analysis of Variance and Chi Square tests.
  
  
  RESULTS
  The proportion of completed fields on the mandatory antenatal forms varied from 100% (maternal age) to 52.7% (pre-pregnancy body mass index). Generally, documentation of care was similar across all weight categories for maternal and prenatal genetic screening tests, ranging from 54.0% (documentation of gonorrhea/chlamydia tests) to 85.0% (documentation of anatomy scan). Documentation of education topics varied widely, from fetal movement in almost all charts across all weight categories but discussion of preterm labour in only 20.6%, 12.7% and 13.4% of normal weight, overweight and obese women's charts (p = 0.224). Across all weight categories, documentation of discussion of exercise, breastfeeding and pain management occurred in less than a fifth of charts.
  
  
  CONCLUSIONS
  Despite a predominance of excess weight in our region, as well as increasing perinatal risks with increasing maternal weight, weight-related issues and other elements of prenatal care were suboptimally documented across all maternal weight categories, despite an obesity guideline.
authors.affiliation: Division of Maternal-Fetal Medicine, Departments of Obstetrics & Gynecology and Diagnostic Imaging and Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main St, West, HSC 3N52B, Hamilton, ON L8S4K1, Canada. mcdonals@mcmaster.ca.
authors.forename: Sarah D
authors.initials: SD
authors.lastname: McDonald
authors.forename: Clea A
authors.initials: CA
authors.lastname: Machold
authors.forename: Laura
authors.initials: L
authors.lastname: Marshall
authors.forename: Dawn
authors.initials: D
authors.lastname: Kingston
mesh_terms: D000328:Adult; D015992:Body Mass Index; D001835:Body Weight; D001942:Breast Feeding; D004282:Documentation / Q000592:standards*; D015444:Exercise; D005260:Female; D005820:Genetic Testing; D019983:Guideline Adherence; D006801:Humans; D008423:Maternal Age; D008499:Medical Records / Q000592:standards*; D009765:Obesity / Q000517:prevention & control; D059408:Pain Management; D010353:Patient Education as Topic; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011295:Prenatal Care; D011296:Prenatal Diagnosis