title: Assessment of the quality of clinical documentation in India's JSY cash transfer program for facility births in Madhya Pradesh.
abstract: OBJECTIVE
  To gain insight into the quality of care in facilities implementing the Janani Suraksha Yojana (JSY) cash transfer program in Madhya Pradesh, India, by reviewing the level of documentation in the clinical records of women who delivered.
  
  
  METHODS
  The present retrospective, descriptive study reviewed case records of women who delivered at 73 primary, secondary, and tertiary level facilities in three districts of Madhya Pradesh between 2012 and 2013. Twenty elements of care were assessed encompassing clinical history and admission details, care during delivery and postnatal period, and discharge details.
  
  
  RESULTS
  A total of 1239 records were reviewed. The extent of documentation varied among the elements assessed-e.g. 24 (1.9%) records documented advice at discharge, 171 (13.8%) documented postnatal blood pressure, 437 (35.3%) documented fetal heart rate, and 1220 (98.5%) documented admission date. The extent of documentation was better at higher level facilities.
  
  
  CONCLUSIONS
  The quality of clinical documentation in the JSY program was found to be unacceptably poor in Madhya Pradesh. Improving staff skills and practices in clinical documentation and record keeping will be required to enable clinical processes to be assessed and quality of care to be improved.
authors.affiliation: Department of Public Health and Environment, R.D. Gardi Medical College, Ujjain, India; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. Electronic address: sarikabharat2005@gmail.com.
authors.forename: Sarika
authors.initials: S
authors.lastname: Chaturvedi
authors.affiliation: Department of Public Health and Environment, R.D. Gardi Medical College, Ujjain, India; Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors.forename: Bharat
authors.initials: B
authors.lastname: Randive
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
authors.forename: Joanna
authors.initials: J
authors.lastname: Raven
authors.affiliation: Department of Public Health and Environment, R.D. Gardi Medical College, Ujjain, India; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; International Centre for Health Research, R. D. Gardi Medical College, Ujjain, India.
authors.forename: Vishal
authors.initials: V
authors.lastname: Diwan
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Ayesha
authors.initials: A
authors.lastname: De Costa
mesh_terms: D000328:Adult; D036861:Delivery, Obstetric / Q000191:economics / Q000592:standards*; D004282:Documentation; D005260:Female; D005380:Financing, Government / Q000379:methods / Q000592:standards*; D006268:Health Facilities / Q000191:economics / Q000592:standards*; D006801:Humans; D007194:India; D008499:Medical Records / Q000592:standards*; D011247:Pregnancy; D015397:Program Evaluation; D011787:Quality of Health Care; D012189:Retrospective Studies
keywords: Cash transfer; Clinical audit; India; Intrapartum care; Medical records; Midwifery; Obstetrics; Quality of care