Shoulder dystocia documentation: an evaluation of a documentation training intervention.

Abstract:

OBJECTIVE:To evaluate the quality and content of nurse and physician shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation. METHODS:Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia between the years of 2000 and 2006 excluding the training year of 2003 were identified. The charts were evaluated for 14 key components derived from a validated instrument. The delivery notes were then scored based on these components by 2 separate investigators who were blinded to delivery note author, date, and patient identification to further quantify delivery record quality. RESULTS:Approximately 346 charts were reviewed for physician and nurse delivery documentation. The average score for physician notes was 6 (maximum possible score of 14) both before and after the training intervention. The nurses' average score was 5 before and after the training intervention. CONCLUSIONS:Negligible improvement was observed in the content and quality of shoulder dystocia documentation before and after nurse and physician training.

journal_name

J Patient Saf

authors

LeRiche T,Oppenheimer L,Caughey S,Fell D,Walker M

doi

10.1097/PTS.0b013e3182948a51

subject

Has Abstract

pub_date

2015-03-01 00:00:00

pages

18-22

issue

1

eissn

1549-8417

issn

1549-8425

journal_volume

11

pub_type

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