A Novel Management Database in Obstetrics and Gynaecology to Introduce the Electronic Healthcare Record and Improve the Clinical Audit Process

摘要

Objectives. To design a system capable of recording complete and accurate electronic patient records with respect to obstetrics and gynaecology, with the ability to perform instant statistically summaries of data. Backgorund: Electronic patient records have been shown to provide numerous benefits for the clinician, with respect to patient consultation, accurate recording of data, medical audit and statistical analysis. In Northern Ireland there is no database designed to cover all the major clinical aspects of obstetrics and gynaecology. This project incorporates all aspects of obstetrics and gynaecology into a single database. Methods: Database designed using Filemaker pro 7, Macromedia Fireworks 8, and Microsoft photodraw. Problems specific to obstetrics and gynaecology included recording multiple pregnancy data, and the lack of a unique patient number (the current system in Northern Ireland gives patients a unique hospital number, and a separate maternity number for each pregnancy). Limking all of these sources was a major component of this database. The database contains many intrinsic tabulations, relationships, programming scripts and calculations to combine files and calculate important statistical information for clinicians automatically. Results: A successful audit of delivery statistics for December 05 was performed using the system. Several additional audits are currently under completion using the database. The major audit, completion date end April 06, is a 5 month summary of delivery data (Dec-April) based on mode of delivery, Robson groups, and Caesarian -Section rate among specified patient sub-groups. Conclusion: The system has been successful in its initial stages with obvious improvements to the medical audit process already apparent. The system should prove to be a valuable addition to the department and ultimately improve patient care. The ability to provide instant access to clinical data and statistics will simplify and improve the audit process, improving clinical governance. The management of the OB/GYN department should benefit greatly.