BACKGROUND:
Preeclampsia is a leading cause of maternal and perinatal morbidity and mortality worldwide, particularly in low- and middle-income countries¹,². Effective epidemiological surveillance depends on accurate, complete, and standardized clinical records. In Brazil’s Unified Health System (SUS), weaknesses in health information systems may compromise disease monitoring, health service planning, and the evaluation of maternal health policies³.

METHODS:
This retrospective, descriptive study analyzed medical records of women who delivered at a public maternity hospital in Araras, São Paulo, Brazil, between January and May 2021. A total of 384 obstetric records were reviewed, with specific analysis of cases diagnosed with preeclampsia. Variables included sociodemographic data, clinical management, pharmacological treatment, and neonatal outcomes, with emphasis on data completeness and consistency.

RESULTS:
The prevalence of preeclampsia was 13.28%. Significant gaps in clinical documentation were identified, including missing information on antihypertensive treatment, gestational age at delivery, and neonatal outcomes. Approximately 20% of records lacked documentation regarding pharmacological management, and several neonatal variables were inconsistently recorded. These deficiencies limited robust epidemiological analysis and may contribute to underreporting and misclassification of cases, impairing surveillance accuracy⁴,⁵.

CONCLUSIONS:
Incomplete clinical records represent a critical barrier to effective epidemiological surveillance of preeclampsia within the SUS. Strengthening health information systems, improving professional training, and standardizing clinical documentation are essential to support evidence-based public health policies, improve maternal health surveillance, and reduce preventable adverse outcomes⁶.