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The sequential effect of computerized delivery charting and simulation training on shoulder dystocia documentation.
Tina Nguyen1, Nathan S Fox, Frederick Friedman
1Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine, New York, NY, USA.
Computerized charting and shoulder dystocia (SD) simulation drills significantly improved the documentation of SD events. Standardized notes enhanced data capture, while drills further increased documented SD rates and provider reporting.
Area of Science:
- Obstetrics and Gynecology
- Medical Informatics
- Patient Safety
Background:
- Shoulder dystocia (SD) is a critical obstetric emergency requiring precise documentation.
- Current documentation practices for SD may be suboptimal, impacting quality assessment and improvement.
Purpose of the Study:
- To evaluate the impact of computerized charting and simulation drills on shoulder dystocia (SD) documentation.
- To assess improvements in the completeness and accuracy of SD records.
Main Methods:
- Retrospective analysis of 180 shoulder dystocia (SD) cases across three periods.
- Comparison of documentation completeness before and after implementing standardized computerized notes and SD simulation drills.
Main Results:
- Standardized computerized notes significantly improved documentation of key variables like estimated fetal weight, anesthesia, and patient discussions.
- Simulation drills further enhanced documentation of delivery instruments, cord pH, and patient discussions.
- Simulation drills also increased the overall rate of documented SD and the proportion of obstetricians documenting SD.
Conclusions:
- Implementing standardized computerized notes for shoulder dystocia (SD) demonstrably improves documentation quality.
- Simulation drills represent an effective strategy to further enhance SD documentation and reporting accuracy.
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