Pre‐printed format improves recording of instrumental vaginal delivery

Abstract

Instrumental vaginal delivery is an area often responsible for indefensible claims. One of the important reasons for this is poor medical record keeping. The standard of record keeping for instrumental vaginal deliveries within our unit was audited with a view to improving deficiencies. A retrospective analysis of 100 case records of women having an instrumental vaginal delivery was made over a period of one year. After identifying deficiencies in the quality of record keeping a pre‐printed standard record form was introduced and a further 50 cases audited. Deficiencies were identified in the documentation of clinical obstetric findings, type of anaesthesia, estimated blood loss, type and size of ventouse cup used. Analysis of cases using the standard record form has demonstrated 100 percent compliance with adequate record keeping.

Citation

Agrawal, A., Ghosh, S. and Lennox, C.E. (2004), "Pre‐printed format improves recording of instrumental vaginal delivery", Clinical Governance: An International Journal, Vol. 9 No. 2, pp. 91-95. https://doi.org/10.1108/14777270410536367