ORIGINAL ARTICLE
Shoulder Dystocia Documentation: An Evaluation of a Documentation Training Intervention Tammy LeRiche, MSc, MD, FRCSC, Lawrence Oppenheimer, MD, FRCSC, FRCOG, Sharon Caughey, MD, FRCSC, Deshayne Fell, MSc, and Mark Walker, MSc, MD, FRCSC
Objective: To evaluate the quality and content of nurse and physician OB
shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation. Methods: Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia between the years of 2000 and 2006 excluding the training year of 2003 were identified. The charts were evaluated for 14 key components derived from a validated instrument. The delivery notes were then scored based on these components by 2 separate investigators who were blinded to delivery note author, date, and patient identification to further quantify delivery record quality. Results: Approximately 346 charts were reviewed for physician and nurse delivery documentation. The average score for physician notes was 6 (maximum possible score of 14) both before and after the training intervention. The nurses’ average score was 5 before and after the training intervention. Conclusions: Negligible improvement was observed in the content and quality of shoulder dystocia documentation before and after nurse and physician training.
judgment will not be made against a physician, it can minimize a finding of negligence. In 2002, the Society of Obstetricians and Gynaecologists of Canada launched its multidisciplinary MOREOB patient safety and risk management program. The Ottawa Hospital (TOH) was included in the initial 21 pilot sites. In late 2003, all TOH obstetrical nursing staff, physicians and residents (PGY-2 and above) underwent training in shoulder dystocia management skills and documentation. Numerous studies illustrate the importance of incorporating shoulder dystocia and related documentation drills into obstetrical skills training.5,6 A review of the literature reveals several studies that evaluate the immediate efficacy of these training drills on documentation content.5,7,8 However, the longterm value of these interventions in the clinical setting has not been evaluated. The purpose of our study is to assess whether there has been long-term improvement in the content and quality of nurse and physician documentation of shoulder dystocia since the MOREOB training.
Key Words: shoulder dystocia, documentation, birth injury, obstetric delivery (J Patient Saf 2015;11: 18Y22)
S
houlder dystocia is defined as impaction of the fetal anterior shoulder behind the maternal symphysis pubis, which results in a delay in the completion of the vaginal delivery. It is an obstetrical emergency and can result in major long-term complications for the newborn including brachial plexus injury, hypoxic brain injury, and death.1 Maternal complications include postpartum hemorrhage, cervical and vaginal trauma, and psychological trauma. The incidence of shoulder dystocia has been reported to range from 0.2% to 3% of all vaginal deliveries.2,3 Although still rare, shoulder dystocia and brachial plexus injuries constitute one of the most common medical malpractice lawsuits brought against obstetricians, representing an estimated 11% of all obstetrical law suits.4 In a study of shoulder dystocia documentation, Deering et al.5 found that accurate and complete documentation was significantly lacking. It has long been recognized that thorough documentation of the delivery management and patient encounter, as well as effective patient communication, are crucial to minimizing the risk of malpractice claims. Although detailed and accurate documentation does not guarantee that a successful
From the Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada. Correspondence: Tammy LeRiche, MSc, MD, FRCSC, 75 Charles Street, Brockville General Hospital, Brockville, ON, K6V 158, Canada (e-mail: [email protected]). The authors disclose no conflict of interest. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved
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METHODS This study was approved by the Ottawa Hospital Research Ethics Board. Charts coded for shoulder dystocia between the years of 2000 and 2006 at the Ottawa General Hospital (General Campus site) were evaluated for quality and content of documentation. The MOREOB shoulder dystocia training was carried out in 2003 over a period of several months. Therefore, charts in 2003 were excluded from the study as they could not be reliably identified as pre or post intervention. Cases of shoulder dystocia occurring between 2000 and 2002 served as the preimplementation period and were compared with cases of shoulder dystocia between 2004 and 2006, after the MOREOB training. A search of the Ottawa Hospital database identified 431 medical charts containing a diagnosis of shoulder dystocia between 2000 and 2006. We reviewed 346 of these as 47 cases occurred in 2003 and 38 charts were disqualified for incorrect coding of shoulder dystocia or absent/incomplete documentation. Formal delivery notes for each chart were evaluated for level of training of the MD (attending, PGY2 or higher, family medicine resident or staff, or medical student), the date and time of delivery, parity, medical personnel present at delivery and neonatal outcomes. Formal delivery documentation (nurse and physician records) was assessed for the criteria listed in Table 1. Finally, the physician and nurse delivery records were scored individually based on the above information with one point being assigned for each completed documentation item (maximum score = 14). Individual ‘‘types of maneuvers’’ were not assigned points but rather one point was assigned if any maneuvers were documented. This was based on the CRABEL scoring method for the standardized quality assessment of medical records9 and was done as a means of quantifying the delivery record quality. J Patient Saf
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Shoulder Dystocia Documentation
RESULTS
TABLE 1. Information Collected From Nursing and Physician Notes in Eligible Charts
A search of the Ottawa Hospital (General Campus) database for mention of shoulder dystocia anywhere in the medical chart produced a total of 384 charts between the years of 2000 and 2006 excluding the MOREOB training year of 2003. Of these, 38 charts were excluded for the following reasons: delivery by cesarean, no shoulder dystocia noted in chart, anticipated shoulder dystocia documented only, charts unavailable, or charts contained incomplete or absent documentation. Approximately 346 charts were therefore assessed. One physician delivery note was absent in the preintervention charts while six were absent in the postintervention charts. There were 3 nursing delivery records absent in the preintervention charts, whereas only one was absent in the postintervention documentation. Approximately 195 cases of shoulder dystocia were recorded before the training session, between 2000 and 2002, whereas 151 were identified between 2004 and 2006. Before the training session, 49% were written by staff, 47% by residents of varying levels, and 3% by medical students. After the training program, 37% were found to be written by staff physicians, whereas 56% were by residents and 7% by medical students. Review of the obstetrical population showed little difference in parity before and after 2003V37% of the women were primiparous before the intervention, whereas 32% were in the postintervention years. Tables 2 through 4 illustrate the physician and nurse documentation of the criteria listed in Table 1. There was a statistically significant improvement in physician documentation of delivery time and the discussion with the patient postintervention. Although there was a slight improvement in physician documentation of date, duration of dystocia, neonatal weight, Apgar score, baby’s condition, pediatrics requested, estimated blood loss, and maneuvers performed, these were not statistically significant. Physician documentation of shoulder dystocia, cord gases, analgesia used and the request for assistance slightly decreased but was not statistically significant. Examination of the nursing notes (Table 3) revealed a slight improvement in documentation of time, date, shoulder dystocia, duration of dystocia, pediatrics requested, estimated
Date and Time of Delivery Time of delivery of the shoulder and head or delivery interval if specific times not documented Shoulder dystocia noted Birth weight Apgars Cord gases Assistance requested Estimated blood loss Notes condition of baby Pediatrics requested Maneuvers recorded Analgesia Discussed with patient *Types of maneuvers used (McRoberts, suprapubic pressure, corkscrew, episiotomy, posterior shoulder delivery, anterior shoulder disimpaction, Zavanelli, and all fours) *The individual maneuvers were not assigned points in the qualitative assessment.
This method was a validated tool designed to assess content of medical documentation through a scoring system and was initially reported in the Annals of the Royal College of Surgeons of England.9 A second expert investigator was used to also score the physician delivery notes. We only gave one point for documentation of maneuvers instead of one per procedure as there was no way to validate what was actually done. Scores were then compared, and any discrepancies were discussed and resolved between the 2 investigators to ensure fair and equal assessment. The date, time, patient identification, and author of the note were removed before evaluation by the investigators to minimize bias. Nursing notes were also assessed in a similar fashion but by one reviewer only.
TABLE 2. Delivery Note Documentation Criteria for Physicians Preintervention (n = 194) Time of delivery Date of delivery Shoulder dystocia noted Dystocia duration Birth weight Apgars Cord gases Notes baby condition Pediatrics consulted Assistance requested Estimated blood loss Maneuvers recorded Analgesia Discussed with patient
n 149 150 176 15 97 118 37 21 49 11 155 123 31 4
% 76.8 77.3 90.7 7.7 50 60.8 19.1 10.8 25.3 5.7 79.9 63.4 16 2.1
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Postintervention (n = 145) n 128 121 127 19 87 95 25 22 43 6 126 105 21 14
% 88.3 83.5 87.6 13.1 60 65.5 17.2 15.2 29.7 4.1 86.9 72.4 14.5 9.7
% Difference (95% CI) 14.9 (4.3Y26.7) 7.9 (j2.9 to 19.9) j3.5 (j10.5 to 4.2) 69.5 (j10.8 to 222) 20 (j1.1 to 45.6) 7.7 (j8.5 to 26.8) j9.6 (j42.9 to 43.1) 40.2 (j19.8 to 144.9) 17.4 (j17.1 to 66.4) j27 (j72.4 to 92.7) 8.8 (j1.1 to 19.6) 14.2 (j1.4 to 32.3) j9.4 (j45.6 to 51) 368.3 (57.4Y1293) www.journalpatientsafety.com
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P 0.009 0.21 0.45 0.15 0.09 0.44 0.78 0.31 0.44 0.71 0.12 0.10 0.83 0.004
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TABLE 3. Delivery Note Documentation Criteria for Nurses
Time of delivery Date of delivery Shoulder dystocia noted Dystocia duration Birth weight Apgars Cord gases Notes baby condition Pediatrics consulted Assistance requested Estimated blood loss Maneuvers recorded Analgesia Discussed with patient
Pre-Intervention (n = 192)
Post-Intervention (n = 150)
n
%
n
%
% Difference (95% CI)
P-Value
188 189 100 47 31 66 0 8 97 28 4 55 190 2
97.9 98.4 52.1 24.5 16.2 34.4 0 4.2 50.5 14.6 2.1 28.7 99 1
150 150 84 69 13 39 2 1 90 17 8 60 146 5
100 100 56 46 8.7 26 1.3 0.7 60 11.3 5.3 40 97.3 3.3
2.1 (0Y4.3) 1.6 (j0.2 to 3.4) 7.5 (j11.6 to 30.8) 87.9 (38.8Y154.4) j46.3 (j70.9 to j1.1) j24.4 (j45.8 to 5.6) Indeterminate j84 (j98 to 26.5) 18.8 (j1.9 to 43.8) j22.3 (j55.8 to 36.5) 156 (j21.4 to 734) 39.6 (3.8Y87.9) j1.6 (j4.6 to 1.4) 220 (j37 to 1526)
0.20 0.35 0.54 G0.0001 0.06 0.12 0.38 0.08 0.10 0.47 0.19 0.04 0.47 0.27
dystocia, neonatal weight, Apgar score, gases, baby’s condition, estimated blood loss, maneuvers used, and discussion with the mother. Table 4 shows the maneuvers described in the charts to resolve the cases of shoulder dystocia. There was an increase in physician documentation of the McRoberts maneuver, anterior shoulder disimpaction, suprapubic pressure, and posterior shoulder delivery; however, only documentation of the latter two increased significantly. In this chart review, there were no cases where the ‘‘all four’’ position or the Zavanelli maneuver were
blood loss, maneuvers performed and discussion with the mother. However, only documentation of dystocia duration and maneuvers was statistically significant. Documentation of neonatal weight, Apgar score, baby’s condition, request for assistance, and analgesia used slightly decreased but was not statistically significant. In comparison to physician documentation, nurse records showed superior documentation of time, date, dystocia duration, pediatrics and assistance requested, and analgesia used. Physician notes showed better-quality documentation of shoulder
TABLE 4. Maneuvers Recorded by Physicians and Nurses Preintervention (n = 194)
Postintervention (n = 145)
Physicians
n
%
n
%
McRoberts Suprapubic pressure Episiotomy Posterior shoulder delivery Corkscrew Anterior shoulder disimpaction All fours
87 60 35 32 22 11 0
44.9 30.9 18 16.5 11.3 5.7 0
78 63 26 42 15 14 0
53.8 43.4 17.9 29 10.3 9.7 0
19.9 (j3.5 to 49) 40.5 (6.1Y86) j0.6 (j37.2 to 57.4) 75.6 (17Y163.7) j8.8 (j50.9 to 69.6) 70.3 (j20.4 to 264) Indeterminate
Nurses
Preintervention (n = 192)
Postintervention (n = 150)
% difference (95% CI)
McRoberts Suprapubic pressure Episiotomy Posterior shoulder delivery Corkscrew Anterior shoulder disimpaction All fours
n 24 36 9 5 1 1 0
n 39 42 16 11 1 1 0
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% 12.5 18.7 4.7 2.6 0.5 0.5 0
% 26 28 10.7 7.3 0.7 0.7 0
% Difference (95% CI)
108 (31.1Y230) 49.3 (1.1Y120.7) 127.6 (3.5Y400.5) 181.6 (0Y692.9) 28 (j91.9 to 1929) 28 (j91.9 to 1929) Indeterminate
P 0.13 0.02 90.99 0.009 0.91 0.24 V P 0.002 0.06 0.06 0.07 90.99 90.99 V
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Shoulder Dystocia Documentation
TABLE 5. Quantitative Assessment of Physicians and Nursing Delivery Notes Care Provider
Preintervention Mean (SD)
Postintervention Mean (SD)
P*
Physicians Nurses
5.9 (1.7) 5.2 (1.7)
6.5 (2.1) 5.5 (1.8)
0.003 0.11
*P value based on Student t test.
used. Among nurses, there was an increase in documentation of all maneuvers; however, only the McRoberts maneuver was significant. Table 5 shows the quantitative scores of physician and nursing documentation. Both physician and nursing notes do show a slight improvement postintervention; however, only the physician score was statistically significant.
DISCUSSION Thorough documentation of shoulder dystocia management has long been recognized to be an essential part of obstetrical record keeping.7,10,11 Although there have been a number of studies illustrating the importance and immediate effectiveness of shoulder dystocia drills and documentation education, there are no studies that evaluate the long-term clinical value of these interventions.5Y7 Contrary to the literature, our study shows that there was little difference in both physician and nursing documentation of shoulder dystocia after completion of the MOREOB shoulder dystocia training sessions at the Ottawa Hospital General Campus site. A slightly greater number of notes were written by staff in the preintervention years (49% compared with 37%). Approximately 56% of the postintervention notes were written by residents and 7% by medical students, whereas 47% and 3% were written pretraining, respectively. This slight difference in authorship training is not likely to impact the overall quality and content of notes. However, not all of these residents would have taken the course, and medical students are often trained by residents. Staff is required to approve the paperwork, so inadvertently the staff that was trained is responsible for note quality and content. With respect to the individual criteria listed in Tables 2 through 4, nursing notes were far superior to physicians’ for recording time and date. Although physician notes showed improvement in these criteria after the training (77%Y88% for time and 77%Y83% for date), they remained inferior to nursing records (98%Y100% for both criteria). Interestingly, physician notes were superior to those of nursing in documenting that shoulder dystocia had occurred both before and after the intervention. The training seemed to have had minimal impact on either group (physician, 91%Y88%; nurse, 52%Y56%) with the nursing notes showing a small, nonsignificant improvement and the physician notes showing a slight decline. In cases of mild shoulder dystocia, it is often resolved quickly with minimal discussion between physician and nursing personnel. Although the physician may recognize and record the event, the nurse may be unaware of its occurrence and therefore not record it. This may explain the discrepancy. Nursing notes documented the head-to-delivery time interval far more frequently than physician notes. Nursing headto-delivery time interval documentation increased by 88% (P G 0.0001) after the training intervention. In a shoulder dystocia situation, extra nursing staff is often present and one is designated * 2015 Wolters Kluwer Health, Inc. All rights reserved
as the scribe. This facilitates the recording of time intervals accurately. Unfortunately, the discrepancy between physician and nursing documentation of this key element illustrates a lack of communication within the birthing team where the physician does not seem to consolidate their record with the nurses to include the time interval. Weight, Apgar scores, gases, and condition of the baby were all reported to a greater extent in the physician notes. Nursing notes showed a slight, nonsignificant decline in documentation for 3 of these postintervention. This may be a result of the introduction of a standardized birth record in 2005/2006 which includes prompts for the above elements. Nursing staff, attending neonatal team, and delivering physician will complete these boxes on the form, thereby not placing this information in their formal notes as previously done. For this study, it was actual nursing and physician written notes that were used in the assessment of documentation quality. Furthermore, at our institution, Apgar scores and neonate condition are often recorded by the neonatal team who are present at deliveries involving shoulder dystocia, meconium, vacuum or forceps assisted deliveries, and abnormal fetal heart rate tracings. As this information was formally recorded elsewhere, documentation of this by the assessed personnel may be missing. Surprisingly, both physicians and nurses poorly recorded that assistance was requested. This did not improve with the training intervention (physician, 6%Y4%; nurse, 15%Y11%). In mild shoulder dystocia, assistance is sometimes not requested as the dystocia is resolved with the initial maneuver. Ideally, this fact should be stated in the delivery note. Nurses did report the request for assistance more frequently. Often, when dystocia is recognized, the nursing staff is very quick to request assistance from other nurses. The majority of delivering physicians at our institution are obstetricians and do not request other physician assistance as they are often not available. Ideally, a complete delivery note would record the request for both nursing and physician assistance. Documentation of estimated blood loss and the presence of pediatrics for both physicians and nurses improved nonsignificantly. There was a slight decrease in the documentation of analgesia used for both nurses and physicians (16%Y14% for physicians and 99%Y97% for nurses). Recording estimated blood loss is considered to be a key part of a complete delivery note, and so, this was well documented in the physician notes (80%Y87% versus 2%Y5% for nursing notes). Often, pediatrics is not called for mild shoulder dystocia cases that resolve with initial maneuvers. However, as with assistance requests, this should be documented. Nursing notes were superior in recording both the presence of pediatrics (51%Y60% versus 25%Y30% for physicians) and analgesia used. At our institution, nurses often manage analgesia in labor with the initiation of nitrous oxide gas or the request for an epidural without physician orders. As a result, their documentation of this criterion is likely to be higher. Physician documentation of the maneuvers was found to be greater than that of the nursing documentation. Improvement was noted after the intervention for both groups (MD, 63%Y72%; nurse, 29%Y40%). Table 4 shows the individual maneuvers described in the charts to resolve the cases of shoulder dystocia. As expected, McRoberts and suprapubic pressure were the most frequently used maneuvers documented by both physicians and nurses. Interestingly, nurses noted suprapubic to be used more often than McRoberts. This is most likely due to the fact that nurses generally perform this maneuver once shoulder dystocia has been recognized. There was a large difference between nurse and physician documentation of anterior shoulder disimpaction, www.journalpatientsafety.com
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posterior shoulder delivery and corkscrew maneuvers with physicians recording this much more frequently. These maneuvers are performed by the physicians often without discussion with the nursing staff present making nursing recognition of these maneuvers challenging. In general, physicians recorded maneuvers more than nurses. In this chart review, there were no cases where the ‘‘all four’’ position or the Zavanelli maneuver were used. Regrettably, the frequency with which patient discussions were recorded was low for both groups. There was a 3-fold increase in documentation by physicians after the training; however, it remained very low among nurses. Event discussion is very important for patient communication, and documentation of this discussion is vital from a medicolegal perspective.4,6 An assessment of the overall quality of the notes was then pursued (Table 5). As quality assessment can be subjective, we attempted to use a standardized scoring system to ensure fairness and minimize bias. The CRABEL score is a validated method that was devised by Crawford et al. for the standardized auditing of medical record quality.9 The initial protocol assigned a score of 50 to each note and subtracted points from this maximum score for missing predefined data. We modified this scoring method by assigning each desired criterion one point for a maximum score of 14. Two blinded reviewers scored charts separately, and any discrepancies in scores were resolved between the reviewers through discussion. Our findings showed a small statistically significant improvement in the quality of the physician delivery notes (5.9Y6.5, P = 0.003). Nursing note quality improved non-significantly (5.2Y5.5, P = 0.11). One may expect that the documentation would be superior initially after the training intervention as reported in other studies. However, the average score for physician notes in 2004 was 6.75 T 2.2, whereas nursing notes was 5.65 T 1.9. This further illustrates the lack of improvement in quality of documentation after the training. There were several limitations of this study. Our institution introduced a new standardized live birth record containing a series of check boxes and prompts in approximately 2005/2006. This form includes categories for shoulder dystocia and duration of dystocia as well as time, date, estimated blood loss, Apgar score, neonatal weight, and cord gases. This standardized document is considered by some to be a sufficient delivery note and is completed by both nurses and physicians together with each contributing individual pieces of information. However, only formal written delivery notes were considered for this study. The introduction of this form may have skewed the postintervention data as some physicians and nurses may not have written complete documentation knowing the information was present in this record. Nevertheless, in cases of shoulder dystocia, the attending physician should write a formal delivery note. Quality of nursing notes was not assessed by 2 reviewers as was done for the physician notes. Only 1 reviewer scored these charts. Physician notes were written as concise delivery notes, whereas nursing notes were written in a more summary format involving the whole labor and delivery process. The information was therefore more difficult to identify and make amenable to the review process. Notes were written by a variety of medical personnel at varying stages of educational training. Only senior residents and staff physicians attended the MOREOB shoulder dystocia course.
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Some notes written postintervention were by individuals not having been exposed directly to the intervention. This may have skewed the data to show a decreased degree of improvement in documentation. Unfortunately, we had no way to identify the individuals trained as the study notes were blinded, and we did not have access to the list of individuals who had attended the course. As discussed earlier, the overall quality and content of the delivery notes are the responsibility of the staff physicians, who all attended the documentation-training course.
CONCLUSIONS This study shows a general lack of improvement in the long-term quality and content of physician and nursing shoulder dystocia documentation after a training intervention. It further illustrates dramatic disparities in the content of notes between the groups, suggesting that communication between the responsible nurses and physicians with respect to the event and the subsequent documentation is lacking. This is significant for legal documentation as such discrepancies can suggest mismanagement and potentially discredit the description of the events in question. ACKNOWLEDGMENT The authors thank Dr. Amal Al-Serehi for valuable feedback and comments. REFERENCES 1. Baskett TF, Allen AC. Perinatal implications of shoulder dystocia. Obstet Gynecol. 1995;86:14Y17. 2. Gherman RB, Chauhan S, Ouzounian JG, et al. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol. 2006;195:657Y672. 3. Dandolu V, Lawrence L, Gaughan JP, et al. Trends in the rate of shoulder dystocia over two decades. J Matern Fetal Med. 2005;18:305Y310. 4. Mavroforou A, Koumantakis E, Michalodimitrakis E. Physicians’ liability in obstetric and gynecology practice. Med Law. 2005;24:1Y9. 5. Deering S, Poggi S, Hodor J, et al. Evaluation of residents’ delivery notes after a simulated shoulder dystocia. Obstet Gynecol. 2004;104:667Y670. 6. Crofts JF, Bartlett C, Ellis D, et al. Documentation of shoulder dystocia: accurate and complete? BJOG. 2008;115:1303Y1308. 7. Kwek K, Yeo GSH. Shoulder dystocia injuries: prevention and management. Curr Opin Obstet Gynecol. 2006;18:123Y128. 8. Posner G, Bonin B, Nakajima A. Evaluation of residents’documentation skills after a simulated operative vaginal delivery. JOGC. 2009;31:1064Y1067. 9. Crawford JR, Beresford TP, Lafferty KL. The CRABEL scoreVa method for auditing medical records. Ann R Coll Surg Engl. 2001;83:65Y68. 10. Clark SL, Belfort MA, Dildy GA, et al. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008;112:1279Y1283. 11. Goffman D, Heo H, Chazotte C, et al. Using simulation training to improve shoulder dystocia documentation. Obstet Gynecol. 2008;112:1284Y1287.
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Shoulder Dystocia Documentation: An Evaluation of a Documentation Training Intervention Tammy LeRiche, MSc, MD, FRCSC, Lawrence Oppenheimer, MD, FRCSC, FRCOG, Sharon Caughey, MD, FRCSC, Deshayne Fell, MSc, and Mark Walker, MSc, MD, FRCSC
Objective: To evaluate the quality and content of nurse and physician OB
shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation. Methods: Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia between the years of 2000 and 2006 excluding the training year of 2003 were identified. The charts were evaluated for 14 key components derived from a validated instrument. The delivery notes were then scored based on these components by 2 separate investigators who were blinded to delivery note author, date, and patient identification to further quantify delivery record quality. Results: Approximately 346 charts were reviewed for physician and nurse delivery documentation. The average score for physician notes was 6 (maximum possible score of 14) both before and after the training intervention. The nurses’ average score was 5 before and after the training intervention. Conclusions: Negligible improvement was observed in the content and quality of shoulder dystocia documentation before and after nurse and physician training.
judgment will not be made against a physician, it can minimize a finding of negligence. In 2002, the Society of Obstetricians and Gynaecologists of Canada launched its multidisciplinary MOREOB patient safety and risk management program. The Ottawa Hospital (TOH) was included in the initial 21 pilot sites. In late 2003, all TOH obstetrical nursing staff, physicians and residents (PGY-2 and above) underwent training in shoulder dystocia management skills and documentation. Numerous studies illustrate the importance of incorporating shoulder dystocia and related documentation drills into obstetrical skills training.5,6 A review of the literature reveals several studies that evaluate the immediate efficacy of these training drills on documentation content.5,7,8 However, the longterm value of these interventions in the clinical setting has not been evaluated. The purpose of our study is to assess whether there has been long-term improvement in the content and quality of nurse and physician documentation of shoulder dystocia since the MOREOB training.
Key Words: shoulder dystocia, documentation, birth injury, obstetric delivery (J Patient Saf 2015;11: 18Y22)
S
houlder dystocia is defined as impaction of the fetal anterior shoulder behind the maternal symphysis pubis, which results in a delay in the completion of the vaginal delivery. It is an obstetrical emergency and can result in major long-term complications for the newborn including brachial plexus injury, hypoxic brain injury, and death.1 Maternal complications include postpartum hemorrhage, cervical and vaginal trauma, and psychological trauma. The incidence of shoulder dystocia has been reported to range from 0.2% to 3% of all vaginal deliveries.2,3 Although still rare, shoulder dystocia and brachial plexus injuries constitute one of the most common medical malpractice lawsuits brought against obstetricians, representing an estimated 11% of all obstetrical law suits.4 In a study of shoulder dystocia documentation, Deering et al.5 found that accurate and complete documentation was significantly lacking. It has long been recognized that thorough documentation of the delivery management and patient encounter, as well as effective patient communication, are crucial to minimizing the risk of malpractice claims. Although detailed and accurate documentation does not guarantee that a successful
From the Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada. Correspondence: Tammy LeRiche, MSc, MD, FRCSC, 75 Charles Street, Brockville General Hospital, Brockville, ON, K6V 158, Canada (e-mail: [email protected]). The authors disclose no conflict of interest. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved
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METHODS This study was approved by the Ottawa Hospital Research Ethics Board. Charts coded for shoulder dystocia between the years of 2000 and 2006 at the Ottawa General Hospital (General Campus site) were evaluated for quality and content of documentation. The MOREOB shoulder dystocia training was carried out in 2003 over a period of several months. Therefore, charts in 2003 were excluded from the study as they could not be reliably identified as pre or post intervention. Cases of shoulder dystocia occurring between 2000 and 2002 served as the preimplementation period and were compared with cases of shoulder dystocia between 2004 and 2006, after the MOREOB training. A search of the Ottawa Hospital database identified 431 medical charts containing a diagnosis of shoulder dystocia between 2000 and 2006. We reviewed 346 of these as 47 cases occurred in 2003 and 38 charts were disqualified for incorrect coding of shoulder dystocia or absent/incomplete documentation. Formal delivery notes for each chart were evaluated for level of training of the MD (attending, PGY2 or higher, family medicine resident or staff, or medical student), the date and time of delivery, parity, medical personnel present at delivery and neonatal outcomes. Formal delivery documentation (nurse and physician records) was assessed for the criteria listed in Table 1. Finally, the physician and nurse delivery records were scored individually based on the above information with one point being assigned for each completed documentation item (maximum score = 14). Individual ‘‘types of maneuvers’’ were not assigned points but rather one point was assigned if any maneuvers were documented. This was based on the CRABEL scoring method for the standardized quality assessment of medical records9 and was done as a means of quantifying the delivery record quality. J Patient Saf
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf
&
Volume 11, Number 1, March 2015
Shoulder Dystocia Documentation
RESULTS
TABLE 1. Information Collected From Nursing and Physician Notes in Eligible Charts
A search of the Ottawa Hospital (General Campus) database for mention of shoulder dystocia anywhere in the medical chart produced a total of 384 charts between the years of 2000 and 2006 excluding the MOREOB training year of 2003. Of these, 38 charts were excluded for the following reasons: delivery by cesarean, no shoulder dystocia noted in chart, anticipated shoulder dystocia documented only, charts unavailable, or charts contained incomplete or absent documentation. Approximately 346 charts were therefore assessed. One physician delivery note was absent in the preintervention charts while six were absent in the postintervention charts. There were 3 nursing delivery records absent in the preintervention charts, whereas only one was absent in the postintervention documentation. Approximately 195 cases of shoulder dystocia were recorded before the training session, between 2000 and 2002, whereas 151 were identified between 2004 and 2006. Before the training session, 49% were written by staff, 47% by residents of varying levels, and 3% by medical students. After the training program, 37% were found to be written by staff physicians, whereas 56% were by residents and 7% by medical students. Review of the obstetrical population showed little difference in parity before and after 2003V37% of the women were primiparous before the intervention, whereas 32% were in the postintervention years. Tables 2 through 4 illustrate the physician and nurse documentation of the criteria listed in Table 1. There was a statistically significant improvement in physician documentation of delivery time and the discussion with the patient postintervention. Although there was a slight improvement in physician documentation of date, duration of dystocia, neonatal weight, Apgar score, baby’s condition, pediatrics requested, estimated blood loss, and maneuvers performed, these were not statistically significant. Physician documentation of shoulder dystocia, cord gases, analgesia used and the request for assistance slightly decreased but was not statistically significant. Examination of the nursing notes (Table 3) revealed a slight improvement in documentation of time, date, shoulder dystocia, duration of dystocia, pediatrics requested, estimated
Date and Time of Delivery Time of delivery of the shoulder and head or delivery interval if specific times not documented Shoulder dystocia noted Birth weight Apgars Cord gases Assistance requested Estimated blood loss Notes condition of baby Pediatrics requested Maneuvers recorded Analgesia Discussed with patient *Types of maneuvers used (McRoberts, suprapubic pressure, corkscrew, episiotomy, posterior shoulder delivery, anterior shoulder disimpaction, Zavanelli, and all fours) *The individual maneuvers were not assigned points in the qualitative assessment.
This method was a validated tool designed to assess content of medical documentation through a scoring system and was initially reported in the Annals of the Royal College of Surgeons of England.9 A second expert investigator was used to also score the physician delivery notes. We only gave one point for documentation of maneuvers instead of one per procedure as there was no way to validate what was actually done. Scores were then compared, and any discrepancies were discussed and resolved between the 2 investigators to ensure fair and equal assessment. The date, time, patient identification, and author of the note were removed before evaluation by the investigators to minimize bias. Nursing notes were also assessed in a similar fashion but by one reviewer only.
TABLE 2. Delivery Note Documentation Criteria for Physicians Preintervention (n = 194) Time of delivery Date of delivery Shoulder dystocia noted Dystocia duration Birth weight Apgars Cord gases Notes baby condition Pediatrics consulted Assistance requested Estimated blood loss Maneuvers recorded Analgesia Discussed with patient
n 149 150 176 15 97 118 37 21 49 11 155 123 31 4
% 76.8 77.3 90.7 7.7 50 60.8 19.1 10.8 25.3 5.7 79.9 63.4 16 2.1
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Postintervention (n = 145) n 128 121 127 19 87 95 25 22 43 6 126 105 21 14
% 88.3 83.5 87.6 13.1 60 65.5 17.2 15.2 29.7 4.1 86.9 72.4 14.5 9.7
% Difference (95% CI) 14.9 (4.3Y26.7) 7.9 (j2.9 to 19.9) j3.5 (j10.5 to 4.2) 69.5 (j10.8 to 222) 20 (j1.1 to 45.6) 7.7 (j8.5 to 26.8) j9.6 (j42.9 to 43.1) 40.2 (j19.8 to 144.9) 17.4 (j17.1 to 66.4) j27 (j72.4 to 92.7) 8.8 (j1.1 to 19.6) 14.2 (j1.4 to 32.3) j9.4 (j45.6 to 51) 368.3 (57.4Y1293) www.journalpatientsafety.com
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P 0.009 0.21 0.45 0.15 0.09 0.44 0.78 0.31 0.44 0.71 0.12 0.10 0.83 0.004
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TABLE 3. Delivery Note Documentation Criteria for Nurses
Time of delivery Date of delivery Shoulder dystocia noted Dystocia duration Birth weight Apgars Cord gases Notes baby condition Pediatrics consulted Assistance requested Estimated blood loss Maneuvers recorded Analgesia Discussed with patient
Pre-Intervention (n = 192)
Post-Intervention (n = 150)
n
%
n
%
% Difference (95% CI)
P-Value
188 189 100 47 31 66 0 8 97 28 4 55 190 2
97.9 98.4 52.1 24.5 16.2 34.4 0 4.2 50.5 14.6 2.1 28.7 99 1
150 150 84 69 13 39 2 1 90 17 8 60 146 5
100 100 56 46 8.7 26 1.3 0.7 60 11.3 5.3 40 97.3 3.3
2.1 (0Y4.3) 1.6 (j0.2 to 3.4) 7.5 (j11.6 to 30.8) 87.9 (38.8Y154.4) j46.3 (j70.9 to j1.1) j24.4 (j45.8 to 5.6) Indeterminate j84 (j98 to 26.5) 18.8 (j1.9 to 43.8) j22.3 (j55.8 to 36.5) 156 (j21.4 to 734) 39.6 (3.8Y87.9) j1.6 (j4.6 to 1.4) 220 (j37 to 1526)
0.20 0.35 0.54 G0.0001 0.06 0.12 0.38 0.08 0.10 0.47 0.19 0.04 0.47 0.27
dystocia, neonatal weight, Apgar score, gases, baby’s condition, estimated blood loss, maneuvers used, and discussion with the mother. Table 4 shows the maneuvers described in the charts to resolve the cases of shoulder dystocia. There was an increase in physician documentation of the McRoberts maneuver, anterior shoulder disimpaction, suprapubic pressure, and posterior shoulder delivery; however, only documentation of the latter two increased significantly. In this chart review, there were no cases where the ‘‘all four’’ position or the Zavanelli maneuver were
blood loss, maneuvers performed and discussion with the mother. However, only documentation of dystocia duration and maneuvers was statistically significant. Documentation of neonatal weight, Apgar score, baby’s condition, request for assistance, and analgesia used slightly decreased but was not statistically significant. In comparison to physician documentation, nurse records showed superior documentation of time, date, dystocia duration, pediatrics and assistance requested, and analgesia used. Physician notes showed better-quality documentation of shoulder
TABLE 4. Maneuvers Recorded by Physicians and Nurses Preintervention (n = 194)
Postintervention (n = 145)
Physicians
n
%
n
%
McRoberts Suprapubic pressure Episiotomy Posterior shoulder delivery Corkscrew Anterior shoulder disimpaction All fours
87 60 35 32 22 11 0
44.9 30.9 18 16.5 11.3 5.7 0
78 63 26 42 15 14 0
53.8 43.4 17.9 29 10.3 9.7 0
19.9 (j3.5 to 49) 40.5 (6.1Y86) j0.6 (j37.2 to 57.4) 75.6 (17Y163.7) j8.8 (j50.9 to 69.6) 70.3 (j20.4 to 264) Indeterminate
Nurses
Preintervention (n = 192)
Postintervention (n = 150)
% difference (95% CI)
McRoberts Suprapubic pressure Episiotomy Posterior shoulder delivery Corkscrew Anterior shoulder disimpaction All fours
n 24 36 9 5 1 1 0
n 39 42 16 11 1 1 0
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% 12.5 18.7 4.7 2.6 0.5 0.5 0
% 26 28 10.7 7.3 0.7 0.7 0
% Difference (95% CI)
108 (31.1Y230) 49.3 (1.1Y120.7) 127.6 (3.5Y400.5) 181.6 (0Y692.9) 28 (j91.9 to 1929) 28 (j91.9 to 1929) Indeterminate
P 0.13 0.02 90.99 0.009 0.91 0.24 V P 0.002 0.06 0.06 0.07 90.99 90.99 V
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Shoulder Dystocia Documentation
TABLE 5. Quantitative Assessment of Physicians and Nursing Delivery Notes Care Provider
Preintervention Mean (SD)
Postintervention Mean (SD)
P*
Physicians Nurses
5.9 (1.7) 5.2 (1.7)
6.5 (2.1) 5.5 (1.8)
0.003 0.11
*P value based on Student t test.
used. Among nurses, there was an increase in documentation of all maneuvers; however, only the McRoberts maneuver was significant. Table 5 shows the quantitative scores of physician and nursing documentation. Both physician and nursing notes do show a slight improvement postintervention; however, only the physician score was statistically significant.
DISCUSSION Thorough documentation of shoulder dystocia management has long been recognized to be an essential part of obstetrical record keeping.7,10,11 Although there have been a number of studies illustrating the importance and immediate effectiveness of shoulder dystocia drills and documentation education, there are no studies that evaluate the long-term clinical value of these interventions.5Y7 Contrary to the literature, our study shows that there was little difference in both physician and nursing documentation of shoulder dystocia after completion of the MOREOB shoulder dystocia training sessions at the Ottawa Hospital General Campus site. A slightly greater number of notes were written by staff in the preintervention years (49% compared with 37%). Approximately 56% of the postintervention notes were written by residents and 7% by medical students, whereas 47% and 3% were written pretraining, respectively. This slight difference in authorship training is not likely to impact the overall quality and content of notes. However, not all of these residents would have taken the course, and medical students are often trained by residents. Staff is required to approve the paperwork, so inadvertently the staff that was trained is responsible for note quality and content. With respect to the individual criteria listed in Tables 2 through 4, nursing notes were far superior to physicians’ for recording time and date. Although physician notes showed improvement in these criteria after the training (77%Y88% for time and 77%Y83% for date), they remained inferior to nursing records (98%Y100% for both criteria). Interestingly, physician notes were superior to those of nursing in documenting that shoulder dystocia had occurred both before and after the intervention. The training seemed to have had minimal impact on either group (physician, 91%Y88%; nurse, 52%Y56%) with the nursing notes showing a small, nonsignificant improvement and the physician notes showing a slight decline. In cases of mild shoulder dystocia, it is often resolved quickly with minimal discussion between physician and nursing personnel. Although the physician may recognize and record the event, the nurse may be unaware of its occurrence and therefore not record it. This may explain the discrepancy. Nursing notes documented the head-to-delivery time interval far more frequently than physician notes. Nursing headto-delivery time interval documentation increased by 88% (P G 0.0001) after the training intervention. In a shoulder dystocia situation, extra nursing staff is often present and one is designated * 2015 Wolters Kluwer Health, Inc. All rights reserved
as the scribe. This facilitates the recording of time intervals accurately. Unfortunately, the discrepancy between physician and nursing documentation of this key element illustrates a lack of communication within the birthing team where the physician does not seem to consolidate their record with the nurses to include the time interval. Weight, Apgar scores, gases, and condition of the baby were all reported to a greater extent in the physician notes. Nursing notes showed a slight, nonsignificant decline in documentation for 3 of these postintervention. This may be a result of the introduction of a standardized birth record in 2005/2006 which includes prompts for the above elements. Nursing staff, attending neonatal team, and delivering physician will complete these boxes on the form, thereby not placing this information in their formal notes as previously done. For this study, it was actual nursing and physician written notes that were used in the assessment of documentation quality. Furthermore, at our institution, Apgar scores and neonate condition are often recorded by the neonatal team who are present at deliveries involving shoulder dystocia, meconium, vacuum or forceps assisted deliveries, and abnormal fetal heart rate tracings. As this information was formally recorded elsewhere, documentation of this by the assessed personnel may be missing. Surprisingly, both physicians and nurses poorly recorded that assistance was requested. This did not improve with the training intervention (physician, 6%Y4%; nurse, 15%Y11%). In mild shoulder dystocia, assistance is sometimes not requested as the dystocia is resolved with the initial maneuver. Ideally, this fact should be stated in the delivery note. Nurses did report the request for assistance more frequently. Often, when dystocia is recognized, the nursing staff is very quick to request assistance from other nurses. The majority of delivering physicians at our institution are obstetricians and do not request other physician assistance as they are often not available. Ideally, a complete delivery note would record the request for both nursing and physician assistance. Documentation of estimated blood loss and the presence of pediatrics for both physicians and nurses improved nonsignificantly. There was a slight decrease in the documentation of analgesia used for both nurses and physicians (16%Y14% for physicians and 99%Y97% for nurses). Recording estimated blood loss is considered to be a key part of a complete delivery note, and so, this was well documented in the physician notes (80%Y87% versus 2%Y5% for nursing notes). Often, pediatrics is not called for mild shoulder dystocia cases that resolve with initial maneuvers. However, as with assistance requests, this should be documented. Nursing notes were superior in recording both the presence of pediatrics (51%Y60% versus 25%Y30% for physicians) and analgesia used. At our institution, nurses often manage analgesia in labor with the initiation of nitrous oxide gas or the request for an epidural without physician orders. As a result, their documentation of this criterion is likely to be higher. Physician documentation of the maneuvers was found to be greater than that of the nursing documentation. Improvement was noted after the intervention for both groups (MD, 63%Y72%; nurse, 29%Y40%). Table 4 shows the individual maneuvers described in the charts to resolve the cases of shoulder dystocia. As expected, McRoberts and suprapubic pressure were the most frequently used maneuvers documented by both physicians and nurses. Interestingly, nurses noted suprapubic to be used more often than McRoberts. This is most likely due to the fact that nurses generally perform this maneuver once shoulder dystocia has been recognized. There was a large difference between nurse and physician documentation of anterior shoulder disimpaction, www.journalpatientsafety.com
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posterior shoulder delivery and corkscrew maneuvers with physicians recording this much more frequently. These maneuvers are performed by the physicians often without discussion with the nursing staff present making nursing recognition of these maneuvers challenging. In general, physicians recorded maneuvers more than nurses. In this chart review, there were no cases where the ‘‘all four’’ position or the Zavanelli maneuver were used. Regrettably, the frequency with which patient discussions were recorded was low for both groups. There was a 3-fold increase in documentation by physicians after the training; however, it remained very low among nurses. Event discussion is very important for patient communication, and documentation of this discussion is vital from a medicolegal perspective.4,6 An assessment of the overall quality of the notes was then pursued (Table 5). As quality assessment can be subjective, we attempted to use a standardized scoring system to ensure fairness and minimize bias. The CRABEL score is a validated method that was devised by Crawford et al. for the standardized auditing of medical record quality.9 The initial protocol assigned a score of 50 to each note and subtracted points from this maximum score for missing predefined data. We modified this scoring method by assigning each desired criterion one point for a maximum score of 14. Two blinded reviewers scored charts separately, and any discrepancies in scores were resolved between the reviewers through discussion. Our findings showed a small statistically significant improvement in the quality of the physician delivery notes (5.9Y6.5, P = 0.003). Nursing note quality improved non-significantly (5.2Y5.5, P = 0.11). One may expect that the documentation would be superior initially after the training intervention as reported in other studies. However, the average score for physician notes in 2004 was 6.75 T 2.2, whereas nursing notes was 5.65 T 1.9. This further illustrates the lack of improvement in quality of documentation after the training. There were several limitations of this study. Our institution introduced a new standardized live birth record containing a series of check boxes and prompts in approximately 2005/2006. This form includes categories for shoulder dystocia and duration of dystocia as well as time, date, estimated blood loss, Apgar score, neonatal weight, and cord gases. This standardized document is considered by some to be a sufficient delivery note and is completed by both nurses and physicians together with each contributing individual pieces of information. However, only formal written delivery notes were considered for this study. The introduction of this form may have skewed the postintervention data as some physicians and nurses may not have written complete documentation knowing the information was present in this record. Nevertheless, in cases of shoulder dystocia, the attending physician should write a formal delivery note. Quality of nursing notes was not assessed by 2 reviewers as was done for the physician notes. Only 1 reviewer scored these charts. Physician notes were written as concise delivery notes, whereas nursing notes were written in a more summary format involving the whole labor and delivery process. The information was therefore more difficult to identify and make amenable to the review process. Notes were written by a variety of medical personnel at varying stages of educational training. Only senior residents and staff physicians attended the MOREOB shoulder dystocia course.
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Some notes written postintervention were by individuals not having been exposed directly to the intervention. This may have skewed the data to show a decreased degree of improvement in documentation. Unfortunately, we had no way to identify the individuals trained as the study notes were blinded, and we did not have access to the list of individuals who had attended the course. As discussed earlier, the overall quality and content of the delivery notes are the responsibility of the staff physicians, who all attended the documentation-training course.
CONCLUSIONS This study shows a general lack of improvement in the long-term quality and content of physician and nursing shoulder dystocia documentation after a training intervention. It further illustrates dramatic disparities in the content of notes between the groups, suggesting that communication between the responsible nurses and physicians with respect to the event and the subsequent documentation is lacking. This is significant for legal documentation as such discrepancies can suggest mismanagement and potentially discredit the description of the events in question. ACKNOWLEDGMENT The authors thank Dr. Amal Al-Serehi for valuable feedback and comments. REFERENCES 1. Baskett TF, Allen AC. Perinatal implications of shoulder dystocia. Obstet Gynecol. 1995;86:14Y17. 2. Gherman RB, Chauhan S, Ouzounian JG, et al. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol. 2006;195:657Y672. 3. Dandolu V, Lawrence L, Gaughan JP, et al. Trends in the rate of shoulder dystocia over two decades. J Matern Fetal Med. 2005;18:305Y310. 4. Mavroforou A, Koumantakis E, Michalodimitrakis E. Physicians’ liability in obstetric and gynecology practice. Med Law. 2005;24:1Y9. 5. Deering S, Poggi S, Hodor J, et al. Evaluation of residents’ delivery notes after a simulated shoulder dystocia. Obstet Gynecol. 2004;104:667Y670. 6. Crofts JF, Bartlett C, Ellis D, et al. Documentation of shoulder dystocia: accurate and complete? BJOG. 2008;115:1303Y1308. 7. Kwek K, Yeo GSH. Shoulder dystocia injuries: prevention and management. Curr Opin Obstet Gynecol. 2006;18:123Y128. 8. Posner G, Bonin B, Nakajima A. Evaluation of residents’documentation skills after a simulated operative vaginal delivery. JOGC. 2009;31:1064Y1067. 9. Crawford JR, Beresford TP, Lafferty KL. The CRABEL scoreVa method for auditing medical records. Ann R Coll Surg Engl. 2001;83:65Y68. 10. Clark SL, Belfort MA, Dildy GA, et al. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008;112:1279Y1283. 11. Goffman D, Heo H, Chazotte C, et al. Using simulation training to improve shoulder dystocia documentation. Obstet Gynecol. 2008;112:1284Y1287.
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