Download ANC record review

ANC record review
1
Quality check exercise for ANC records
Each month, in your clinic, health centre, or hospital, examine 20 consecutive antenatal
records as the clients leave the antenatal clinic. For each ANC record, give 1 point for each of
the bulleted items listed below that have been recorded correctly. Half points can be given
where a recording is incomplete. Record the scores on the sheet provided (page 2). Then
total and analyse these scores
History
1. Age, parity and gravidity
2. Details of previous pregnancies, including causes of deaths and indications for operations
3. Previous illnesses that might influence this pregnancy (e.g. cardiac, renal, diabetes).
4. History of the present pregnancy
5. The LMP and the EDD
6. The estimated period of gestation by dates (POGD) correctly recorded or plotted on the
antenatal graph at each visit.
Examination
7. Maternal weight
8. Blood pressure.
9. Examination of heart and lungs
10. Estimation of period of gestation by palpation (POGP) (using SFH in cms and fetal size)
recorded, or plotted on the graph.
11. Estimation whether POGP = POGD, or whether there is evidence of IUGR etc.
12. Fetal presentation recorded from 36 weeks onwards
13. Fetal heart heard or fetal movements felt
14. Urinalysis for proteinuria and glycosuria
15. Haemoglobin and Rh group
16. Syphilis test result recorded
17. Has the client been counselled for HIV testing?
18. Has tetanus toxoid been given?
Interpretations and decisions
19. Identification and recording of risk factors
20. Record of action plan, including interventions and referral if indicated
21. Decision on place for delivery discussed with mother
22. Transport arrangements for when she goes into labour discussed with mother
23. Decision taken by mother re future family planning
24. Have the findings at first visit and 36 weeks visit been double-checked and counter-signed
by an ADM, senior experienced midwife or doctor?
25. Date of next visit.
This will give a maximum score of 25 points. For each ANC card assessed, record:
The total score out of 25. Then multiply by 4 to get a percentage.
ANC record review
2
Summary of Quality Check on ANC records
Hospital/Clinic: ………………………………
Record #
Item #
History
1 Age, parity and gravity
2 Hx of previous pregnancy
3 Previous illnesses
4 Hx of present pregnancy
5 LMP and EDD
6 POGD
Examination
7 Maternal weight
8 BP at each visit
9 Heart and lung examination
10 POGP
11 Cf POGD and POGP
12 Fetal presentation
13 FHH or fetal movement felt
14 Urinanalysis
15 Hb and Rh
16 RPR result recorded
17 HIV counselling
18 ATT given
Interpretation 19 Risk factors identified
and
20 Action plan
decision
21 Place of delivery
22 Transport
23 Future family planning
24 Double-checking
25 Date of next visit
Total score
Percentage (Total X 4)
Municipality: ……………………………
1
2
3
4
5
6
7
8
Date: ……………………..
9 10 11 12 13 14 15 16 17 18 19 20 Total
Sub-total