Justification: Labor and delivery room knowledge of women’s HIV serostatus is required to offer appropriate antiretroviral treatment.
Objectives: Determine medical record documentation of prenatal HIV serostatus at delivery and compare to women’s report of prenatal testing and to other STDs documentation.
Methods: We obtained prenatal and hospital admission medical records for 398 women delivering in 1997 at four hospitals in central North Carolina whom we had interviewed within 24 to 48 hours of delivery.
Results: Medical records documented that 42% had HIV seronegative test results during pregnancy (prenatal tests). Another 20% recorded negative tests either prior to pregnancy or date unknown (non-prenatal tests). 13% demonstrated test refusals. 22% had no documentation of testing; and 3% indicated missing results. One woman was HIV-infected. Lack of documentation varied by hospital (range 10%-34%) and payment for prenatal care (public 13%, private 30%, P<.01). Of 263 women who reported being tested, 59% had prenatal tests; 21% had non-prenatal tests; 14% had no documentation; 2% had documented test refusals; and 4% were missing results. Of 135 women who reported no testing, 5% had prenatal tests; 16% had non-prenatal tests; 39% had no documentation; and 39% had documented test refusals; one was seropositive. Few women lacked documentation for hepatitis B, syphilis, and gonorrhea test results (4%-7%) but many (43%) lacked chlamydia documentation.
Significance: Whether due to errors in charting or lack of testing, the HIV test information available to health care workers attending laboring women is greatly inadequate. Testing for other STDs is more thoroughly documented.
Learning Objectives: 1. Describe the patterns of medical record documentation of HIV testing and other STD testing during pregnancy 2.Compare the medical record documentation of testing to women's report of prenatal testing. 3. Articulate the importance of accurate documentation of prenatal testing to the prevention of mother-to-child HIV transmission
Keywords: HIV Interventions, Prenatal Care
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: None
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.