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Clinical audits
Ref Number: APCP-PP-127

Documentation Compliance of Key Neonatal Parameters in the Child Health Development Record (CHDR): A Clinical Audit at GSFHW

Udari Ruwanpathirana¹, Jithma Fonseka¹, Rohan Wickramasinghe²
1- German Sri Lanka Friendship Hospital for Women 2- National Hospital, Galle, Sri Lanka
Corresponding Author: Udari Ruwanpathirana (udarimrp@gmail.com)
Abstract Body
Introduction: The Child Health Development Record (CHDR) is central to continuity of neonatal care in Sri Lanka. Accurate documentation supports growth monitoring, screening follow-up, early risk identification and medico-legal purposes. In routine clinical practice, key neonatal details may be incompletely recorded, affecting continuity and quality of care. Objectives: Assessed the documentation compliance of key ten neonatal parameters mentioned in first and seventh pages of CHDR. Method: A prospective clinical audit was conducted over five weeks at the Well Baby Clinic, GSFHW . Eighty-five first-visit infants with their CHDRs, which were completed by health staff at GSFHW were assessed using a structured proforma. Results: Documentation compliance was highest for birth weight (98%), OFC (75%) and birth length (25%). Lower documentation rates were observed for APGAR score (69%), vitamin K administration (88%) and discharge weight (48%). Congenital hypothyroidism screening by heel prick was documented in only 61% of records. Breastfeeding establishment was documented in 68%, leaving nearly one-third undocumented. Among infants with genuine risk factors (n = 54), documentation of the need for special care was only 28%, indicating missed opportunities for appropriate follow-up. Overall documentation non-compliance for screening for critical congenital heart disease was 25% and represents a major patient safety concern warranting further evaluation. Conclusion: Although basic anthropometric parameters were documented, critical perinatal and screening information showed major gaps. Targeted staff training, checklist-based documentation, assigning responsibility for CHDR completion and regular re-audits are recommended to improve documentation quality and continuity of neonatal care and strengthen long-term neonatal follow-up and service delivery outcomes.
Keywords: Documentation compliance; Health development; Key neonatal parameters
Presentation Type: Clinical audits
Disclaimer: The Views and opinions expressed in the articles are of the authors and not of the journal.
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