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Accuracy of obstetric laceration diagnoses in the electronic medical record

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Abstract

Introduction and hypothesis

Patient safety data including rates of obstetric anal sphincter injury (OASI) are often derived from hospital discharge codes. With the transition to electronic medical records (EMRs), we hypothesized that electronic provider-entered delivery data would more accurately document obstetric perineal injury than traditional billing/diagnostic codes.

Methods

We evaluated the accuracy of perineal laceration diagnoses after singleton vaginal deliveries during one calendar year at an American tertiary academic medical center. We reviewed the entire hospital chart to determine the most likely laceration diagnosis and compared that expert review diagnosis (ExpRD) with documentation in the EMR delivery summary (EDS) and ICD-9 diagnostic codes (IDCs).

Results

We retrospectively selected 354 total delivery records. OASI complicated 56 of those. 303 records (86%) were coded identically by the EDS and IDCs. Diagnoses from the IDCs and the EDS were mostly correct compared with ExpRD (sensitivity = 96%, specificity = 100%). There was no systematic over- or under-diagnosis of OASI for either the EDS (p = 0.070) or the IDCs (p = 0.447). When considering all laceration types the EDS was correct for 21 (5.9%) lacerations that were incorrect according to the IDCs. Overall, the EDS was more accurate (p < 0.05) owing to errors in IDC minor laceration diagnoses.

Conclusions

Electronic medical record delivery summary data and EMR-derived diagnostic codes similarly characterize OASI. The EDS does not improve OASI reporting, but may be more accurate when considering all perineal lacerations. This assumes that providers have correctly identified and categorized the lacerations that they record in the EMR.

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Acknowledgements/funding

This publication was supported by the UCDenver Department of Obstetrics and Gynecology and an unrestricted quality improvement grant from Pfizer Pharmaceuticals. KJH was supported by a Society for Maternal Fetal Medicine/American Association of Obstetricians and Gynecologists Foundation Scholar award. REDCap use was supported in part by NIH/NCRR Colorado CTSI Grant Number UL1 RR025780. Data analysis was supported by NIH/NCATS Colorado CTSI Grant Number UL1 TR000154. The contents of this publication are the authors’ sole responsibility and do not necessarily represent official NIH views.

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA

    Brian Wakefield

  2. Department of Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA

    Sindi Diko

  3. Department of Emergency Medicine, University of Chicago, Chicago, IL, USA

    Racheal Gilmer

  4. Division of Urogynecology, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

    Kathleen A. Connell

  5. Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

    Kathleen A. Connell & K. Joseph Hurt

  6. Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

    Peter E. DeWitt

  7. Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, 12700 East 19th Avenue, Mail Stop 8613, Aurora, CO, 80045, USA

    K. Joseph Hurt

Authors
  1. Brian Wakefield
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  2. Sindi Diko
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  3. Racheal Gilmer
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  4. Kathleen A. Connell
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Contributions

B. Wakefield: project development, manuscript writing. S. Diko: manuscript writing, manuscript editing; R. Gilmer: project development, data collection, data analysis, manuscript editing; K.A. Connell: project development, manuscript editing; P.E. DeWitt: project development, data analysis, manuscript editing; K.J. Hurt: project development, data collection, manuscript writing.

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Correspondence to K. Joseph Hurt.

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Wakefield, B., Diko, S., Gilmer, R. et al. Accuracy of obstetric laceration diagnoses in the electronic medical record. Int Urogynecol J 32, 1907–1915 (2021). https://doi.org/10.1007/s00192-020-04450-x

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