Improvement in documentation using an electronic checklist for shoulder dystocia deliveries.

Abstract

To estimate if using an electronic checklist improved the documentation of shoulder dystocias that occurred at our institution. A standard checklist of key elements that should be included in the delivery note after a shoulder dystocia was added to the electronic delivery note at our institution. We identified shoulder dystocia deliveries from the department's delivery database for 3 years before and after the checklist was included and compared delivery notes written from these time periods with respect to their content. Forty-six shoulder dystocia deliveries were identified before the checklist being available and 82 after. There was a significant increase noted in the frequency with which several elements were documented after the checklist was implemented including McRoberts maneuver (before checklist 69%, compared with after checklist 90%, P=.003), head-to-body interval (22% compared with 84%, P<.001), which shoulder was anterior (48% compared with 96%, P<.001), and if the neonate was moving its arms after delivery (50% compared with 93%, P<.001). Use of a standard checklist for shoulder dystocia in the delivery note resulted in a significant improvement in the documentation of several critical elements. II.