Except for the two indicators "Documentation of risk classification in clinical record" and "Documentation of risk classification in the clinical record summary sheet" all risk classifications are based on documented risk classification where available or, if there was no clear documented risk classification, assessment by auditor applying an algorithm to clinical data available in the record.
The remaining indicators measuring compliance, as well as six indicators measuring documentation by chart review, showed a compliance below 80%% before and after e-learning.
However, according to our power-calculation, for most of the indicators on documentation enough measurements were available for reliable analysis.
The scores in the indicators measuring documentation in the medical charts of compliance to the CPG (1 6) were low before and after the intervention.
It includes a better use of logical framework approaches; smarter objectives and indicators; good documentation of results at output, outcome and impact levels; and more systematic application of good practices of monitoring and evaluation.
Quality of care indicators for documentation of assessment and correctness of treatment (drugs/fluids) were identified and compared against guidelines to establish if differences existed in the process of care on weekdays compared to weekends.
Our findings illustrate how PRCs sought to reconcile the competing functions of the prenatal record as a comprehensive clinical guide for a range of health indicators, a legal documentation tool, and a data source for perinatal health surveillance.
But these results have to be interpreted cautiously taking the limitations into account: the discriminatory capacity is not yet assessed and the assessment of the indicators relies on documentation only [ 17].
We requested records for 395 procedures (96% of those with an indicator) and received adequate documentation for 209 (53%) (Table 2).
Such databases can be limited, especially where indicators depend on precise documentation of issues such as communication, patient-reported outcomes or preferences [ 9]; such information can only be obtained from patients and their families themselves.
