Department of Research and Evaluation, University Research Co., LLC, Bethesda, Maryland, USA.
BMJ Open. 2013 Apr 24;3(4). doi: 10.1136/bmjopen-2013-002554. Print 2013.
Improvement activities, surveillance and research in maternal and neonatal health in Afghanistan rely heavily on medical record data. This study investigates accuracy in delivery care records from three hospitals across workshifts.
Observational cross-sectional study.
The study was conducted in one maternity hospital, one general hospital maternity department and one provincial hospital maternity department. Researchers observed vaginal deliveries and recorded observations to later check against data recorded in patient medical records and facility registers.
We determined the sensitivity, specificity, area under the receiver operator characteristics curves (AUROCs), proportions correctly classified and the tendency to make performance seem better than it actually was.
600 observations across the three shifts and three hospitals showed high compliance with active management of the third stage of labour, measuring blood loss and uterine contraction at 30 min, cord care, drying and wrapping newborns and Apgar scores and low compliance with monitoring vital signs. Compliance with quality indicators was high and specificity was lower than sensitivity. For adverse outcomes in birth registries, specificity was higher than sensitivity. Overall AUROCs were between 0.5 and 0.6. Of 17 variables that showed biased errors, 12 made performance or outcomes seem better than they were, and five made them look worse (71% vs 29%, p=0.143). Compliance, sensitivity and specificity varied less among the three shifts than among hospitals.
Medical record accuracy was generally poor. Errors by clinicians did not appear to follow a pattern of self-enhancement of performance. Because successful improvement activities, surveillance and research in these settings are heavily reliant on collecting accurate data on processes and outcomes of care, substantial improvement is needed in medical record accuracy.
阿富汗母婴健康领域的改进活动、监测和研究工作严重依赖于病历数据。本研究调查了三个医院不同班次分娩护理记录的准确性。
观察性横断面研究。
这项研究在一家妇产医院、一家综合医院妇产科和一家省医院妇产科进行。研究人员观察阴道分娩，并记录观察结果，然后与患者病历和医疗机构登记册中记录的数据进行核对。
我们确定了敏感性、特异性、受试者工作特征曲线下面积（AUROC）、正确分类比例和表现倾向于优于实际表现的程度。
三个班次和三个医院共 600 次观察结果显示，积极管理第三产程、测量产后 30 分钟出血量和子宫收缩、脐带护理、新生儿干燥和包裹、阿普加评分的依从性较高，而监测生命体征的依从性较低。质量指标的依从性较高，特异性低于敏感性。对于出生登记处的不良结局，特异性高于敏感性。总体 AUROC 在 0.5 到 0.6 之间。在 17 个显示偏倚误差的变量中，有 12 个使表现或结果看起来比实际情况更好，有 5 个使表现或结果看起来更差（71%比 29%，p=0.143）。三个班次之间的依从性、敏感性和特异性变化小于医院之间的变化。
病历的准确性普遍较差。临床医生的错误似乎没有表现出自我提高绩效的模式。由于这些环境中的成功改进活动、监测和研究严重依赖于收集护理过程和结果的准确数据，因此需要大幅提高病历的准确性。
