Auditing documentation on delivery room management using video and physiological recordings.

Area of Science:

• Neonatology
• Medical Documentation
• Quality Improvement

Background:

• Retrospective documentation of neonatal resuscitation is common.
• This practice can lead to inaccuracies and incomplete records of delivery room management.
• Accurate documentation is crucial for assessing and improving care.

Purpose of the Study:

• To assess the accuracy and completeness of neonatal resuscitation documentation.
• To compare recorded data with medical record entries.
• To identify areas for improvement in documentation practices.

Main Methods:

• Collected physiological parameters and video data during neonatal resuscitation.
• Compared recorded data with existing medical records (paper and digital).
• Evaluated documentation accuracy for clinical condition, interventions, and Apgar scores.

Main Results:

• Delivery room management was documented in 93% of records.
• Clinical condition at birth (76%) and 1-min Apgar scores (98%) were frequently documented.
• Accuracy varied significantly for physiological parameters: heart rate (37%), oxygen saturation (13%).
• Intubation was correctly documented in 57% of cases.
• Apgar score agreement between recordings and records improved over time (33% at 1 min to 53% at 10 min).

Conclusions:

• Accurate and complete documentation of neonatal resuscitation remains a challenge.
• Physiological parameter and video recordings offer a more detailed and accurate record.
• Implementing recording technologies can enhance the quality of neonatal resuscitation documentation.