Documentation of abuse to pregnant women: A medical chart audit in public health clinics

Abuse during pregnancy has been measured to affect 16% of women, with adverse consequences for both maternal health and infant birthweight. To determine the rate of documented assessment of abuse during pregnancy, a random sample of 540 maternity records from three innercity public health clinics was evaluated. The clinics serve 9364 new maternity patients yearly, some 95% of which are Hispanic, with total maternity visits numbering 41,195. Four (0.74%) of the 540 charts documented abuse. None of the documentation included frequency of abuse, extent of injuries, or follow-up referrals. After the chart review, staff training was completed at the clinics in the use of a designated protocol of assessment and intervention plan. Testing of staff about facts on abuse revealed good understanding, with 47% of the staff reporting asking female clients about partner violence within the last 6 months. These results indicate that health professionals are asking women about abuse but are not documenting the abuse in the medical record. The need for a designated abuse assessment form and protocol of care as part of standard medical care is discussed.