Quality of prenatal care data in Basic Care in electronic medical records and relationship with matrix support, Vitória, Espírito Santo, 2013-2014: cross-sectional

Abstract

Objective: To evaluate the quality dimensions of the electronic medical records data of pregnant women followed in the Primary Health Care of Vitória, Espírito Santo, and to compare their completeness with health care models (Traditional Basic Units and Family Health with and without Matrix Support). Methods: Cross-sectional study of the dimensions of quality in the prenatal clinical records using the electronic medical record of pregnant women in the city of Vitória, Espírito Santo, Brazil from January 1, 2013 to December 31, 2014. The following were evaluated: coverage, non-duplicity, accessibility, opportunity, methodological clarity, completeness, consistency and reliability. Results: Excluding duplicate records, 690 medical records were analyzed. Prenatal coverage, considering the onset of prenatal care, was 80%. Even with the restriction of access, opportunity and lack of methodological clarity, the clinical record showed excellent consistency and completeness in the fields of obstetric procedures and laboratory tests. Variables as maternal race, marital status, pregnancy planning and gestational risk presented poor completeness, varying according to health assistance model. Reliability was not completely in agreement with the Live Births Information System. Conclusions: There is potential of the electronic medical record as a source of epidemiological information on prenatal care. However, its reliability is hampered by the lack of integration of data with other levels of attention and information systems and its completeness is deficient in some aspects. The data suggest that the presence of the Matrix Support does not significantly influence the completeness of the medical record. Greater emphasis on completing medical records and integrating with other levels of care is necessary.