An essential part of all medical care is the effective management of patient health information. Many types of error, including many types of diagnoses and treatments, have their roots in decisions that have been based on incomplete information.  While the inherent risk to patient safety associated with handoffs has been well documented in the literature, patient handoff from the out-patient to the inpatient setting has received less attention. In the obstetric environment, an incomplete patient handoff due to the absence of a prenatal record can potentially lead to an adverse event that can affect two connected but separate patients.
      At Sharp Mary Birch Hospital for Women several hundred prenatal records were sent to the hospital each day from multiple physician offices via hand delivery, mail and fax. A common occurrence was for an individual's prenatal record to be misplaced and not available when the patient presented for hospital care. These misplaced and otherwise unavailable prenatal records were a considerable source of frustration for physicians and other care providers and prompted the development and implementation of an electronic document retrieval system for prenatal record management.  This presentation describes how electronic document retrieval technology was utilized to promote patient safety, and improve quality of care by eliminating the problem of missing prenatal  records.