Objective Accurate documentation in healthcare is necessary for ethical, legal, research and quality improvement purposes. In this review, we aimed to evaluate the accuracy of methods of documentation of delivery room resuscitations.
Methods A systematic literature search in MEDLINE was conducted to identify original studies that reported the quality of documentation records during newborn resuscitation in the delivery room. Data extracted from the studies included population characteristics, methodology, documentation protocols, use of gold standard and main results (initial assessment of heart rate and peripheral oxygen saturation, respiratory support and supplementary oxygen).
Results In total, 197 records were screened after initial database search, of which seven studies met the inclusion criteria and were finally included in this review. Four studies were chart reviews and three studies compared conventional documentation methods with video recording. Only one study tested an intervention to improve documentation. Documentation was often inaccurate and important resuscitation events and interventions were poorly recorded. Lack of uniformity among studies preclude pooled analysis, but it seems that complex or advanced procedures were more accurately reported than basic interventions.
Conclusions There is little literature regarding accuracy of documentation during neonatal resuscitation, but current quality of documentation seems to be unsatisfactory. There is a need for consensus guidelines and innovative solutions in newborn resuscitation documentation.
- data collection
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Contributors AA-A and MT conceived the systematic review. The protocol was created by AA-A, MT and PGD. Searches were performed by AA-A. All search results were reviewed by AA-A and MT. The first draft of the manuscript was written by AA-A. MT, PGD and COFK edited and reviewed the manuscript, making important intellectual contributions. Final version was approved by AA-A, MT, PGD and COFK.
Funding This work was supported by NHMRC Practitioner Fellowship (PGD), NHMRC Centre of Research Excellence in Newborn Medicine (PGD, MT), NHMRC Programme Grant Improving Neonatal Outcomes (PGD, MT, COFK) and Spanish Neonatal Society (SENeo) grants for training stays in national and international neonatal units 2019–2020 (AA-A).
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study. All data relevant to the study are included in the article or uploaded as supplementary information. No unpublished data are available for this study.
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