OBJECTIVE: To develop, implement, and evaluate an electronic record that tracks antepartum, intrapartum, and postpartum care. METHODS: The Standard Obstetric Record Charting system (STORC) was created by a group of programmers and clinicians who developed screen designs, reports, pick lists, and standard notes, and ensured a flexible, yet standard system. To evaluate data within the system, ORYX (Joint Commission) performance measures were collected retrospectively and compared with STORC data. RESULTS: The STORC, officially implemented as our complete inpatient and outpatient obstetric record in March 1998, provided seamless integration of antepartum, intrapartum, and postpartum care records, standard forms, and standard and ad hoc reports. Data for customizable case and procedure lists are generated easily. Unplanned and total cesarean deliveries were identified retrospectively in 0% (0 of 18) of charts reviewed for ORYX; however, STORC identified the actual rates of each as 8.3% (23 of 276) and 12.3% (34 of 276), respectively. Other critical ORYX measures not identified by retrospective data collection, but accurately provided by STORC, included rates of third and fourth degree lacerations, postpartum hemorrhage, low and extremely low birth weights, and macrosomia. CONCLUSION: After implementation in a large referral center, completeness and accuracy of charting and rapid access to obstetric outcome data were improved. Provider acceptance of the system also was dramatic and improved over time as a result of direct development oversight by obstetric health care providers, local control of system changes, and immediate access to outcome data. (Obstet Gynecol 2000;96:1003-8.)
OBJECTIVE: To develop, implement, and evaluate an electronic record that tracks antepartum, intrapartum, and postpartum care. METHODS: The Standard Obstetric Record Charting system (STORC) was created by a group of programmers and clinicians who developed screen designs, reports, pick lists, and standard notes, and ensured a flexible, yet standard system. To evaluate data within the system, ORYX (Joint Commission) performance measures were collected retrospectively and compared with STORC data. RESULTS: The STORC, officially implemented as our complete inpatient and outpatient obstetric record in March 1998, provided seamless integration of antepartum, intrapartum, and postpartum care records, standard forms, and standard and ad hoc reports. Data for customizable case and procedure lists are generated easily. Unplanned and total cesarean deliveries were identified retrospectively in 0% (0 of 18) of charts reviewed for ORYX; however, STORC identified the actual rates of each as 8.3% (23 of 276) and 12.3% (34 of 276), respectively. Other critical ORYX measures not identified by retrospective data collection, but accurately provided by STORC, included rates of third and fourth degree lacerations, postpartum hemorrhage, low and extremely low birth weights, and macrosomia. CONCLUSION: After implementation in a large referral center, completeness and accuracy of charting and rapid access to obstetric outcome data were improved. Provider acceptance of the system also was dramatic and improved over time as a result of direct development oversight by obstetric health care providers, local control of system changes, and immediate access to outcome data. (Obstet Gynecol 2000;96:1003-8.)
Authors: Emily Oken; Karen Switkowski; Sarah Price; Lauren Guthrie; Elsie M Taveras; Matthew Gillman; Jonathan Friedes; William Callaghan; Patricia Dietz Journal: Matern Child Health J Date: 2013-10
Authors: Chad D Meyerhoefer; Susan A Sherer; Mary E Deily; Shin-Yi Chou; Lizhong Peng; Tianyan Hu; Marion Nihen; Michael Sheinberg; Donald Levick Journal: J Am Med Inform Assoc Date: 2017-04-01 Impact factor: 4.497