Electronic Health Record Documentation of Cannabis Use in Pregnancy: A retrospective chart review

Introduction: Cannabis is the most commonly used federally illicit drug during pregnancy. Despite its rising prevalence, there are few well-controlled studies evaluating the impact of prenatal cannabis use (PCU) on fetal development, and clinical guidelines addressing PCU are limited. This study examines electronic health record (EHR) documentation of PCU to better understand how PCU is addressed within obstetric encounters.Methods: A retrospective chart review was performed on 8,323 patients with pregnancy outcomes in 2023 at a Midwestern healthcare system. Patients with and without documented PCU were identified using ICD-10 codes and positive urine drug screen (UDS) results. A random sample of patients was then selected for chart review: 64 with and 68 without documented PCU.Results: PCU prevalence in our sample was 11.3% (937/8,323). We identified 477 patients with a cannabis-related diagnosis, 829 with a positive UDS, and 369 with both. Qualitative assessment of individual chart reviews demonstrates that PCU is frequently recorded without an accompanying ICD-10 diagnosis, appearing instead in open notes or as a positive UDS lab result. Provider documentation of actions to address PCU varied widely, and patient-provider discussions about PCU were not consistently documented.Conclusions/Implications: These preliminary data reveal considerable variability in PCU documentation within the EHR of a large healthcare system, which may be due to stigma surrounding cannabis use, available clinic resources, or lack of prioritization and provider comfort in addressing PCU. Findings underscore the need for standardized protocols to address PCU in obstetric settings, particularly in the context of increased cannabis legalization.