Clinical Documentation Completeness in Orofacial Cleft Care Across High-Resource and Surgical Mission Settings: A Cross-Sectional Study

Objective To compare documentation completeness between preoperative records for children with orofacial cleft treated at a high-resource U.S. pediatric center and an itinerant surgical mission program. Design Cross-sectional analysis of a previously published, harmonized 2-cohort orofacial cleft dataset. Setting A U.S. tertiary pediatric craniofacial center (Children's Hospital of Philadelphia [CHOP]) and a CHOP-affiliated surgical mission program serving patients in Guatemala City. Patients, Participants All 817 preoperative records in the deposited dataset (684 CHOP, 2012-2019; 133 mission, 2017-2020); none were excluded. The deposit carries no patient identifier, and the source publication reports 514 CHOP and 115 mission patients, so records, not patients, are the unit of analysis. Interventions None (observational). Main Outcome Measures Documentation completeness of weight, syndromic status, comorbidity, family history, and prior-repair history, and a calculated per-record composite completeness score (0-1). Results Documentation was less complete in the mission cohort for every field, with risk differences for documentation completeness ranging from −0.29 (95% CI, −0.37 to −0.22) for family history to −0.80 (95% CI, −0.86 to −0.73) for weight (all P < .001). Mean composite completeness was 0.986 at CHOP versus 0.421 in the mission cohort (bootstrap mean difference, −0.56; 95% CI, −0.61 to −0.52). Gaps persisted after adjustment for age and cleft type. Conclusions Documentation completeness differed markedly by care setting within 1 shared instrument. The 5 affected fields are the only universally applicable history-dependent items in a 35-variable instrument; making them mandatory is a small change that would let mission cohorts support the same analyses as high-resource cohorts.