title: Current practice of neonatal resuscitation documentation in North America: a multi-center retrospective chart review.
abstract: BACKGROUND
  To determine the comprehensiveness of neonatal resuscitation documentation and to determine the association of various patient, provider and institutional factors with completeness of neonatal documentation.
  
  
  METHODS
  Multi-center retrospective chart review of a sequential sample of very low birth weight infants born in 2013. The description of resuscitation in each infant's record was evaluated for the presence of 29 Resuscitation Data Items and assigned a Number of items documented per record. Covariates associated with this Assessment were identified.
  
  
  RESULTS
  Charts of 263 infants were reviewed. The mean gestational age was 28.4 weeks, and the mean birth weight 1050 g. Of the infants, 69 % were singletons, and 74 % were delivered by Cesarean section. A mean of 13.2 (SD 3.5) of the 29 Resuscitation Data Items were registered for each birth. Items most frequently present were; review of obstetric history (98 %), Apgar scores (96 %), oxygen use (77 %), suctioning (71 %), and stimulation (62 %). In our model adjusted for measured covariates, the institution was significantly associated with documentation.
  
  
  CONCLUSIONS
  Neonatal resuscitation documentation is not standardized and has significant variation. Variation in documentation was mostly dependent on institutional factors, not infant or provider characteristics. Understanding this variation may lead to efforts to standardize documentation of neonatal resuscitation.
authors.affiliation: Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Children's Hospital at Dartmouth, One Medical Center Drive, Lebanon, NH, 03756, USA. matthew.s.braga@hitchcock.org.
authors.forename: Matthew S
authors.initials: MS
authors.lastname: Braga
authors.affiliation: Kapi'olani Medical Center for Women and Children, Neonatology, 1319 Punahou St, Honolulu, HI, 96826, USA. kabburpm@yahoo.com.
authors.forename: Prakash
authors.initials: P
authors.lastname: Kabbur
authors.affiliation: Wellspan Health, York Hospital, Neonatology, 1001 S. George St., York, 17403, NY, USA. mealur@gmail.com.
authors.forename: Pradeep
authors.initials: P
authors.lastname: Alur
authors.affiliation: Wellspan Health, York Hospital, Neonatology, 1001 S. George St., York, 17403, NY, USA. mgoodstein@wellspan.org.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Goodstein
authors.affiliation: University of Minnesota Masonic Children's Hospital, Neonatology, 2450 Riverside Ave, Minneapolis, MN, 55454, USA. rober694@umn.edu.
authors.forename: Kari D
authors.initials: KD
authors.lastname: Roberts
authors.affiliation: University of Minnesota Masonic Children's Hospital, Neonatology, 2450 Riverside Ave, Minneapolis, MN, 55454, USA. ksatrom@gmail.com.
authors.forename: Katie
authors.initials: K
authors.lastname: Satrom
authors.affiliation: McMaster University, McMaster Children's Hospital, Neonatology, 1200 Main St W, Hamilton, ON, L8N 3Z5, Canada. shivan@mcmaster.ca.
authors.forename: Sandesh
authors.initials: S
authors.lastname: Shivananda
authors.affiliation: McMaster University, McMaster Children's Hospital, Neonatology, 1200 Main St W, Hamilton, ON, L8N 3Z5, Canada. iroygoswami@gmail.com.
authors.forename: Ipsita
authors.initials: I
authors.lastname: Goswami
authors.affiliation: University of Connecticut Health Center, Connecticut Children's Medical Center, Neonatology, 282 Washington St., Farmington, 06106, CT, USA. pappagallo@uchc.edu.
authors.forename: Mariann
authors.initials: M
authors.lastname: Pappagallo
authors.affiliation: University of Connecticut Health Center, Connecticut Children's Medical Center, Neonatology, 282 Washington St., Farmington, 06106, CT, USA. cbriere@connecticutchildrens.org.
authors.forename: Carrie-Ellen
authors.initials: CE
authors.lastname: Briere
authors.affiliation: Texas Children's Hospital, Baylor College of Medicine, Neonatology, 6621 Fannin St, Houston, TX, 77030, USA. gksuresh@bcm.edu.
authors.forename: Gautham
authors.initials: G
authors.lastname: Suresh
mesh_terms: D004282:Documentation / Q000592:standards*; D005865:Gestational Age; D006801:Humans; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight; D007363:Intensive Care Units, Neonatal; D008499:Medical Records / Q000592:standards*; D009656:North America; D012151:Resuscitation; D012189:Retrospective Studies