Effect of Implementing a Standardized Shoulder Dystocia Documentation Form on Quality of Delivery Notes.
Complete and accurate documentation by the delivering provider in cases of shoulder dystocia is critical for providing clinical information and care to the patient and protecting providers from litigation risks. Standardized forms improve inclusion of certain data elements in the medical record, but the impact on subsequent narrative notes is unknown. We aimed to determine if implementation of a standardized shoulder dystocia documentation form improves obstetric provider written narrative delivery notes.



In February 2005, our institution introduced a mandatory, standardized shoulder dystocia form containing 29 discrete data points relevant to shoulder dystocia documentation. We identified all deliveries complicated by shoulder dystocia from 1 year before and 4 years after implementation of this form and analyzed medical records for inclusion of delivery information in both the required form and the narrative delivery notes.



We identified 52 cases before and 100 cases after implementation of the standardized form. Inclusion of elements from the form in narrative delivery notes increased significantly after implementation (P = 0.01). Elements present at higher rates included prepregnancy maternal weight (13% before vs 28% after, P = 0.043), total maternal weight gain (19% vs 36%, P = 0.03), estimated fetal weight (60% vs 77%, P = 0.03), duration of active labor (40% vs 65%, P < 0.01), duration of second stage (27% vs 52%, P < 0.01), and time of delivery from head to body (4% vs 30%, P < 0.01).



Use of a mandatory shoulder dystocia documentation form is associated with significant improvement in the comprehensiveness of delivering provider narrative notes and may encourage more complete and accurate charting. Such improvements can allow for more complete and accurate explanation of events to patients and better demonstrate adherence to standards of care in the management of shoulder dystocia and may improve litigation defensibility.
From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
Lisa C
LC
Zuckerwise
Department of Obstetrics and Gynecology, Banner Good Samaritan Medical Center, and the University of Arizona College of Medicine-Phoenix, Phoenix, AZ.
Madison M
MM
Hustedt
From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
Heather S
HS
Lipkind
USF Health, University of South Florida, Tampa, FL.
Edmund F
EF
Funai
Yale-New Haven Hospital, New Haven, CT.
Cheryl A
CA
Raab
From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
Christian M
CM
Pettker
D004282:Documentation / Q000592:standards*; D005260:Female; D006801:Humans; D008499:Medical Records / Q000592:standards*; D011247:Pregnancy; D011787:Quality of Health Care / Q000592:standards*; D012189:Retrospective Studies; D000080883:Shoulder Dystocia / Q000628:therapy*