Electronic fetal monitoring. Are we meeting documentation standards?
OBJECTIVE
To test whether fetal heart rate documentation requirements for high-risk pregnancies are too stringent to achieve compliance, especially during the second stage of labor.


METHODS
Random retrospective chart and monitor strip review of deliveries occurring one year earlier were reviewed. Thirty-four low-risk and 34 high-risk pregnancies were selected and assessed for compliance with nationally accepted documentation guidelines.


RESULTS
All monitor strips and charts were successfully retrieved from medical records. Charted documentation of the strips met national requirements in the active phase of the first stage of labor in 97% of cases, as did documentation during the second stage. For high-risk pregnancies, compliance during the active phase of the first stage of labor was 65% as compared to 35% in the second stage. All infants had normal five-minute Apgar scores, and none had umbilical arterial acidemia.


CONCLUSIONS
Given current resources, we cannot reliably meet established documentation standards for high-risk pregnancies. Such overly stringent documentation standards pose a significant risk in cases going to litigation. A standard should be developed that is based on outcome data.
Hankins
G D
GD
Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston 77555-0587, USA.
Leicht
T
T
Anderson
G D
GD
Rowe
T F
TF
D000328:Adult; D004282:Documentation / Q000592:standards*; D005260:Female; D005323:Fetal Monitoring / Q000592:standards*; D006340:Heart Rate, Fetal; D006801:Humans; D008499:Medical Records / Q000592:standards; D017063:Outcome Assessment, Health Care; D010349:Patient Compliance; D011247:Pregnancy; D011256:Pregnancy Outcome; D018566:Pregnancy, High-Risk; D012016:Reference Values; D012189:Retrospective Studies