Evaluation of residents' documentation skills after a simulated operative vaginal delivery

We sought to evaluate the role of the physician as communicator by assessing obstetrics trainees' documentation of a simulated operative vaginal delivery.

Nineteen residents in obstetrics and gynaecology (PGY-2 to PGY-5) participated in a simulation exercise involving an operative vaginal delivery on a high-fidelity mannequin. After the session, the residents were asked to document the events of the delivery as they would in a standard progress note. The residents' notes were then evaluated for the presence of 14 elements that the Society of Obstetricians and Gynaecologists of Canada has determined are essential in the appropriate documentation of an operative vaginal delivery.

Sixty-three percent (12/19) of trainees documented at least 10 of the 14 elements required, with a range of 7 to 13 elements included. The elements that were most likely to be documented were the instrument used (100%, 19/19) and the number of contractions during which traction was applied (94.7%, 18/19). The elements that were least likely to be included were the location of application of the instrument (15.8%, 3/19) and the amount of traction applied with the instrument (0%, 0/19).

Simulation can be used as a form of standardized formative evaluation to assess trainees' written communication skills and to identify deficiencies.