Current Documentation in the Delivery Room and Strategies for Improvement

Current neonatal resuscitation program standards recommend the use of real-time documentation completed by a designated scribe. Accurate documentation of resuscitation interventions after delivery is an important component of future care for the newborn.

The purpose of this article was to review current practices in the documentation of neonatal resuscitation practices, how technology is currently used in this setting, and to discuss interventions for increasing accuracy and completion of documentation moving forward.

A narrative literature review was performed with studies found on CINAHL, Scopus, and PubMed databases. The literature was reviewed for current documentation practices in the delivery room across different hospitals. Other studies assessing accuracy and technologic interventions for increasing accuracy were also included.

Documentation differs immensely across institutions. Without the use of real-time recording, it is inaccurate, especially in providing a timeline of interventions. Real-time recording was the most accurate and can be technology supported through an app or video recording the resuscitation.

Few studies exist assessing current practices across institutions for documenting neonatal resuscitations and how standardizing practices can improve care of neonates. Further research on this topic and potential interventions for practice improvement should be completed. Interventions such as tablet applications or video recordings, with or without the use of artificial intelligence, have been shown to improve documentation practices. Real-time recording should be prioritized in the delivery room setting aided by a designated recorder, video recording of the resuscitation, and a computer or tablet application.