Accuracy of real-time delivery room resuscitation documentation.

OBJECTIVE: To assess the accuracy of real-time delivery room resuscitation documentation.
DESIGN: Retrospective observational study.
SETTING: Level 3 academic neonatal intensive care unit. PARTICIPANTS: Fifty infants with video recording of neonatal resuscitation. MAIN OUTCOME MEASURES: Vital sign assessments and interventions performed during resuscitation. The accuracy of written documentation was compared with video gold standard.
RESULTS: Timing of initial heart rate assessment agreed with video in 44/50 (88%) records; the documented heart rate was correct in 34/44 (77%) of these. Heart rate and oxygen saturation were documented at 5 min of life in 90% of resuscitations. Of these, 100% of heart rate and 93% of oxygen saturation values were correctly recorded. Written records accurately reflected the mode(s) of respiratory support for 89%-100%, procedures for 91%-100% and medications for 100% of events.
CONCLUSION: Real-time documentation correctly reflects interventions performed during delivery room resuscitation but is less accurate for early vital sign assessments. © Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.