Department of Obstetrics & Gynecology, Nassau University Medical Center, East Meadow, MD, USA.
Department of Business Management, Brooklyn College of the City University of New York, 2900 Bedford Avenue, Brooklyn, NY, 11210, USA.
J Med Syst. 2021 Jan 7;45(1):14. doi: 10.1007/s10916-020-01692-6.
Postpartum visits may provide patients with an inadequate amount of counseling on postpartum depression, birth spacing, healthy eating, exercise, or changes in sexual response and emotions. We created a template in our electronic health record (EHR) with the aid of our clinical informatics department to increased adherence with recommended counseling guidelines. We retrospectively reviewed the postpartum visits of 200 patients who had a delivery and received postpartum care. Patients were seen in a resident-run clinic: 100 visits occurred prior to implementation of the template, while 100 visits occurred post-implementation with use of the template. We observed for documentation of counseling on Pap smear, birth spacing, breastfeeding, contraception, depression, gestational diabetes mellitus, pre-eclampsia, and sleep/fatigue. Descriptive statistics of mean and standard deviation were used to describe the continuous variables. Frequency and percentage were used to describe the continuous variables. Analysis of variance compared the continuous variables. The Pearson chi-square test compared the categorical variables. In visits that occurred without use of the template, counseling was charted as low as 1.0% for birth spacing to as high as 86.0% for contraception. With use of the template, counseling was charted as 100% in all visits for each of the recommended counseling guidelines (all p < 0.001). In conclusion, an EHR template for documentation of postpartum visits is associated with resident adherence with recommended postpartum counseling guidelines. Managers in hospitals and clinical practices should consider incorporating OBGYN-specific EHR note templates to improve quality and increase adherence with recommended guidelines during postpartum visits.
产后访视可能无法为患者提供足够的产后抑郁、生育间隔、健康饮食、运动或性反应和情绪变化方面的咨询。在临床信息学部门的帮助下，我们在电子健康记录（EHR）中创建了一个模板，以提高对推荐咨询指南的遵守率。我们回顾性地审查了 200 名接受分娩和产后护理的患者的产后访视记录。患者在住院医生管理的诊所就诊：100 次就诊发生在模板实施之前，而 100 次就诊发生在使用模板之后。我们观察了巴氏涂片、生育间隔、母乳喂养、避孕、抑郁、妊娠糖尿病、子痫前期和睡眠/疲劳方面的咨询记录。使用均值和标准差的描述性统计数据来描述连续变量。使用频率和百分比来描述分类变量。方差分析用于比较连续变量。皮尔逊卡方检验用于比较分类变量。在没有使用模板的就诊中，生育间隔的咨询记录低至 1.0%，而避孕的咨询记录高达 86.0%。使用模板后，所有推荐咨询指南的咨询记录在所有就诊中均为 100%（所有 p < 0.001）。总之，用于记录产后访视的 EHR 模板与住院医生遵守推荐的产后咨询指南相关。医院和临床实践的管理人员应考虑在妇产科 EHR 记录模板中加入特定模板，以提高质量并在产后访视期间提高对推荐指南的遵守率。
