Objective To assess the accuracy of real-time delivery room resuscitation documentation.
Design Retrospective observational study.
Setting Level 3 academic neonatal intensive care unit.
Participants Fifty infants with video recording of neonatal resuscitation.
Main outcome measures Vital sign assessments and interventions performed during resuscitation. The accuracy of written documentation was compared with video gold standard.
Results Timing of initial heart rate assessment agreed with video in 44/50 (88%) records; the documented heart rate was correct in 34/44 (77%) of these. Heart rate and oxygen saturation were documented at 5 min of life in 90% of resuscitations. Of these, 100% of heart rate and 93% of oxygen saturation values were correctly recorded. Written records accurately reflected the mode(s) of respiratory support for 89%–100%, procedures for 91%–100% and medications for 100% of events.
Conclusion Real-time documentation correctly reflects interventions performed during delivery room resuscitation but is less accurate for early vital sign assessments.
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