Significant improvement in quality of caesarean section documentation with dedicated operative proforma--completion of the audit cycle

Abstract

In the current climate of rising caesarean section rates coupled with the increasingly litigious nature of modern medical practice, and particularly obstetrics, well-documented operative notes are important.

We therefore set out to audit the quality of caesarean section documentation in a busy Greater London University Hospital with over 4500 deliveries per annum. The study involved 137 case notes between 1 November and 31 December 1999 and the same number at re-audit 2 years later. The results of the initial audit showed important omissions in a high percentage of operative delivery notes, with less than 80% of case notes documenting skin incision time and type, surgical findings of note, type of uterine incision, presenting part, explanation of fetal delivery, uterine cavity check, presence of a paediatrician, adnexal check and complete sutures used. CNST (Clinical Negligence Scheme for Trusts) guidelines were not adhered to, with only 41% and 35% of delivery notes having complete signature with printed name and correct time and date, respectively. There was considerable confusion at the use of the terminology for level of urgency of non-elective sections and the umbilical cord blood gas results were also poorly documented. As a consequence of these findings a dedicated 'operative delivery note' proforma was designed according to CNST guidelines, with clear areas for particular details of note such as the clinician's name and grade, cord pH results as well as the more important surgical findings. It also simplified the documentation of the urgency of the procedure. There was a significant improvement in almost all items assessed. We therefore conclude that the use of a specific dedicated operative proforma leads to significantly improved documentation with potentially beneficial medicolegal implications.