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Auditing documentation on delivery room management using video and physiological recordings
  1. K Schilleman,
  2. R S Witlox,
  3. J J van Vonderen,
  4. E Roegholt,
  5. F J Walther,
  6. A B te Pas
  1. Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
  1. Correspondence to Kim Schilleman, Division of Neonatology, Department of Pediatrics, Leiden University Medical Centre, J6-S, P.O. Box 9600, Leiden 2300 RC, The Netherlands; k.schilleman{at}lumc.nl

Abstract

Objective Neonatal resuscitation is often retrospectively documented, which can lead to inaccuracy and incomplete recording of delivery room management. In this study, we assessed the accuracy and completeness of neonatal resuscitation documentation in our neonatal intensive care unit.

Methods Recordings of physiological parameters and video data were performed in the delivery room and used to deduct the clinical condition of the infant, the interventions done and their effect on the infant's condition. The data from the recordings were compared with the documentation on neonatal stabilisation in the medical records (paper or digital).

Results Recordings of 54 infants were compared with the documentation in their medical records. In 93% of the medical records delivery room management was documented. The clinical condition of the infant at birth was documented in 76% and 1 min Apgar scores in 98%. Respiratory support was correctly documented in 83%, heart rate in 37% and oxygen saturation in 13%. In 57% use of supplemental oxygen and its indication were correctly reported. Seven infants were intubated and this was correctly documented in 57%. Apgar scores were compared between the recordings and the medical records. At 1 min, 5 min and 10 min after birth the Apgar score, given by the researcher using the recordings, was similar to the scores in the medical records in 33%, 44% and 53%, respectively.

Conclusions Accurate and complete documentation of neonatal resuscitation continues to be a challenge. Recordings of physiological parameters and video imaging can improve documentation by providing detailed information.

  • Neonatology
  • Resuscitation
  • Audit
  • Monitoring

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