The use of chart reviews to assess substance use one-year postpartum was examined in this pilot study by comparing interviews with chart reviews for 23 women assessed positive for risk during pregnancy. There was no indication that providers asked about alcohol use in 83 percent of the charts, drug use in 57 percent of the charts, and tobacco use in 26 percent of the charts. Few positive or negative matches between interviews and chart reviews were found because substance use was generally not noted. These findings underscore the need to interview women to obtain postpartum substance use information and suggest that providers may not adequately address this issue.
Using chart reviews to assess postpartum substance abuse. A pilot study
Authors: Midanik LT; Armstrong MA; Lieberman L; Osejo VG
Soc Work Health Care. 2004;38(4):25-35.