Abstract

ESPIRITO SANTO, Rita; SALGADO, Catarina; VALENTE, Sandra  and  SALDANHA, Joana. Quality of data in Pregnancy Health Record: the importance for the neonatologist. Nascer e Crescer [online]. 2017, vol.26, n.1, pp.11-20. ISSN 0872-0754.

Introduction: The Pregnancy Health Record (PHR) is a functional tool that allows the sharing of pregnancy data among health care professionals. This information is particularly important in the assessment of the newborn immediately after delivery. The purpose of this study was to analyse the quality of these records. Methods: PHR data were collected from a convenience sampling of puerperal women admitted in the Obstetrics Service between March and June 2014. The quality of the records was evaluated according to the recommendations of Direção Geral de Saúde (DGS). SPSS 20® was used for data analysis (statistically significant p <0.05). Results: The final sample was composed by 468 puerperae. The pregnancy was monitored in 98% of the cases, 44% of which in a Health Care Center (HCC), 21% in a private obstetrician (PO), 24% in the hospital and 11% in multiple places. Correct records were found for blood type in 96% of the cases, blood count in 60%, gestational diabetes screening in 59%, group B streptococcus screening in 76%, ultrasounds in 87%, HIV in 64%, HBV in 72%, and for toxoplasmosis in 66%. No significant differences in these records considering the care unit where pregnancy was monitored. There was a statistically significant association between pregnancy surveillance in the HCC and correct records for syphilis and tetanus vaccination (p<0,001). Although the DGS does not recommend routine screening for CMV and VHC, a relationship between these serology records and pregnancy monitoring in PO was found. (p<0,001 and p=0,03). Conclusion: The majority of records were considered correct, however a greater completeness and uniformity of pregnancy records is still necessary, so that the paediatrician can have accurate pregnancy clinical information for the first observation of the newborn.

Keywords : Pregnancy health record; prenatal care; pregnancy complications; newborn health; maternal serum screening tests.

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