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Accuracy of real-time delivery room resuscitation documentation
Claire E Fishman1, Danielle D Weinberg2, Ashley Murray3
1Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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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Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.