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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