Standard obstetric record charting system: evaluation of a new electronic medical record.

OBJECTIVE

To develop, implement, and evaluate an electronic record that tracks antepartum, intrapartum, and postpartum care.

METHODS

The Standard Obstetric Record Charting system (STORC) was created by a group of programmers and clinicians who developed screen designs, reports, pick lists, and standard notes, and ensured a flexible, yet standard system. To evaluate data within the system, ORYX (Joint Commission) performance measures were collected retrospectively and compared with STORC data.

RESULTS

The STORC, officially implemented as our complete inpatient and outpatient obstetric record in March 1998, provided seamless integration of antepartum, intrapartum, and postpartum care records, standard forms, and standard and ad hoc reports. Data for customizable case and procedure lists are generated easily. Unplanned and total cesarean deliveries were identified retrospectively in 0% (0 of 18) of charts reviewed for ORYX; however, STORC identified the actual rates of each as 8.3% (23 of 276) and 12.3% (34 of 276), respectively. Other critical ORYX measures not identified by retrospective data collection, but accurately provided by STORC, included rates of third and fourth degree lacerations, postpartum hemorrhage, low and extremely low birth weights, and macrosomia.

CONCLUSION

After implementation in a large referral center, completeness and accuracy of charting and rapid access to obstetric outcome data were improved. Provider acceptance of the system also was dramatic and improved over time as a result of direct development oversight by obstetric health care providers, local control of system changes, and immediate access to outcome data. (Obstet Gynecol 2000;96:1003-8.)