Documentation audit on CTG from a large single tertiary hospital in India

Dr J Pawan , Dr Tanya Buckshee Rohatgi , Dr Bela Makhija , Dr Seep Sethi

Background CTG is the most commonly used method for monitoring fetal heart rate and uterine contractions . Correct documentation of CTG is crucial for effective clinical decision-making , improving patient outcome , early detection of potential risk and ensuring compliance with clinical guidelines.

Aims Assess our compliance to the NICE and FIGO guidelines on documentation aspect of CTG recordings Identify potential gaps or deficiencies Provide recommendations To improve quality of care.

Gold Standard NICE and FIGO guidelines on CTG documentation to determine the compliance level.

Audit Methodology 50 random CTG recordings were reviewed prospectively at Max Smart Saket Hospital, Delhi,India Audit was done from 1st October to 31stDecember 2024. We set at at-least 90% adherence as our minimum standard. 

Actions And Recommendations Integration of manual paper CTG recordings with existing electronic clinical notes for seamless clinical handovers and improved quality of care. Standardized integrated electronic checklist for CTG documentation. Daily QC machine check by designated staff . Doctor Stamps with name and designation for accurate documentation in paper CTG records. All paper CTGs to be stored in the designated place in hospital along with digital copies. Staff education and periodic audits.

Audit Checklist	Compliance
1)Name / ID /  Age of the patient noted	100%
2)Paper scale/min noted	100%
3)Starting & Finishing time of the CTG noted	100%
4)Maternal pulse noted	100%
5)Doctor signature noted on paper CTG	100%
6Plan of care documented in the electronic clinical notes	100%
7)Period of gestation noted with term or preterm noted	65%
8)Indication for CTG recorded	60%
9)Induction medication noted	60%
10)CTG interpretation noted	50%
11)Contraction noted in CTG	50%
12)Baseline of fetal heart rate noted	50%
13)Variability noted in CTG	50%
14)Acceleration noted in CTG	50%
15)Deceleration noted in CTG	50%
16)Maternal temperature and blood pressure noted	20%
17)Doctor name and designation recorded on paper CTG	10%
18)Maternal position noted	0%
19)Plan of care documented on CTG paper record	0%
20)Place where CTG  stored documented	0%

Conclusion Suboptimal documentation of CTGs can contribute to poor fetal /maternal outcomes. In countries like India lacking dedicated midwifery care, identifying knowledge gaps is key to developing targeted interventions that improve outcomes and reduce emergency caesarean rates Additional serve as a valuable data resource for education and research.