Quality of records in clinical forms of childbirth in the Maternity Hospital of Lubango, Angola

Abstract

Objective: To describe the quality of clinical records of deliveries and births by quantitative assessing the unfilled variables in birth data collection forms and their implications at Maternity Hospital, in the municipality of Lubango, Angola.

Method: The study was conducted from January to August 2018. It adopted a quantitative research design, analysed variables not filled in a total of 202 birth record forms collected for 3 months (secondary data).

Results: The findings revealed that 80% of the sections of the entire set of information about obstetrical history were not filled in. This occurred with a relatively high frequency resulting in some of the relevant variables being left blank, such as antenatal diagnosis (94%) and the number of last menstruation (91%).

Conclusions: The rate of missing fundamental information from the clinical birth record are high. This result has important implications in evaluating the quality of data and may, consequently, jeopardize: 1) the evaluation of the prenatal assistance, 2) the clinical assistance at delivery, and 3) decision-making for preventive and intervening procedures.

Keywords: Angola; Calidad; Información; Information; Medical records; Obstetricia; Obstetrics; Quality; Registros médicos.