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A retrospective study of use of a standardized shoulder dystocia documentation form suggests that such documentation may improve litigation defensibility. The findings, published in The Journal of Patient Safety, are based on experience at a single institution with a form that captures data on 29 discrete data points.
Investigators from Yale University looked at all deliveries complicated by shoulder dystocia from 1 year before and 4 years after the shoulder dystocia documentation form was implemented. Use of the form became mandatory in 2005. The authors also analyzed medical records to determine whether delivery information had been included in both the shoulder dystocia form and the narrative delivery notes.
A total of 52 deliveries that involved shoulder dystocia were identified before and 100 cases after the form was implemented. After its use became mandatory, inclusion of elements from it in narrative delivery notes increased significantly (P=0.01). Documentation of duration of active labor, duration of second stage, and time of delivery from head to body increased significantly (40% before vs 65% after, 27% vs 52%, and 4% vs 30%, respectively; P<0.001 for both) once the form was in use. With use of the form, there was also a trend toward increased documentation of prepregnancy maternal weight (13% vs 28%; P=0.043), total maternal weight gain (19% vs 36%, P=.03), and estimated fetal weight (60% vs 77%; P=0.03).
“Use of a mandatory shoulder dystocia documentation form,” the authors said, “is associated with significant improvement in the comprehensiveness of delivering provider narrative notes and may encourage more complete and accurate charting.” The improved charting, according to the investigators, may “better demonstrate adherence to standards of care in the management of shoulder dystocia and may improve litigation defensibility.”
Christian Pettker, MD, an author of the study and Contemporary OB/GYN editorial board member, told Contemporary OB/GYN, “The results of this paper are no surprise to anyone familiar with quality and safety principles. Standardization of processes improves completeness and accuracy. What is unique in this study is that we standardized a reporting form with the intent of adding complete and accurate information to the medical record.
“We had no intention of actually impacting the narrative delivery notes. We were impressed that physicians and midwives improved their charting practices in their delivery notes as a result of a documentation tool. These narrative notes are sometimes the keys to recreating the story of the delivery when it comes time to defend the case in litigation. It speaks to the spread of impact of a simple tool like this.”
Zuckerwise LC, Hustedt MM, Lipkind HS, et al. Effect of implementing a standardized shoulder dystocia documentation form on quality of delivery notes. J Patient Saf. 2016 Nov 2. (Epub ahead of print)