Assessment of the quality of clinical documentation in India's JSY cash transfer program for facility births in Madhya Pradesh.

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.

CONCLUSION

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.