Promoting Perinatal Safety Using an Electronic Document Retreival System for Prenatal Record Management in the Obstetric Environment

Thursday, 10 July 2008: 3:55 PM
Karyn Almryde, MSN, RN , Administration, Sharp Mary Birch Hospital for Women, San Diego, CA

Learning Objective 1: understand the how a windows-based, fax server system can be used to improve handoffs from the out-patient to the inpatient setting.

Learning Objective 2: understand key steps involved in developing and implementing an electronic document retrieval system for the management of patient prenatal records.

Documentation of the critical components of the patient's care is necessary for good patient outcomes. Absent or incomplete patient information impedes communication among providers and effects continuity of care adversely from the point of hospital admission. During patient handoffs, if vital patient information is not communicated from one health care provider to another, patient harm may result.

While the inherent risk to patient safety associated with handoffs has been well documented in the literature. One aspect of patient handoff that has received less attention is the transfer of care from the outpatient to the inpatient setting. In the obstetric environment this care transition is especially important because an incomplete handoff due to the absence of a prenatal record can potentially lead to an adverse event that can affect two connected but separate patients. These potential risks supported the necessity to develop an electronic system for prenatal record management that could provide on demand access to patient information 24/7.

A retrospective, multiple-time-series study before and after implementation of the electronic document retrieval system was the research methodology used for this project. Success of the project was based on the presence of a prenatal record in the electronic system at the time of admission to the hospital. Project development included focus group interviews with key stakeholders, gathering information regarding prenatal record process and flow both internally and externally and partnering with the information systems department to build an application to meet the specified needs.

Prior to the implementation of the electronic system the percent of available prenatal records for the pilot- physician group was 84%. After implementation 100% of all faxed records were available upon patient admission. Implementation of the electronic document retrieval system has eliminated the problem of the lost prenatal record and improved patient handoff and communication among providers.