Deering Shad, Poggi Sarah, Hodor Jonathan, Macedonia Christian, Satin Andrew J
Department of Obstetrics and Gynecology, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA.
Obstet Gynecol. 2004 Oct;104(4):667-70. doi: 10.1097/01.AOG.0000137347.94987.01.
To describe and analyze delivery notes after a shoulder dystocia drill with a birthing simulator
A total of 33 residents from 2 university training programs underwent testing on a standardized shoulder dystocia scenario with an obstetric birthing simulator. After the completion of the delivery, each resident was informed of the infant's Apgar scores and birth weight and told that the infant was moving all extremities. The resident was then given a blank progress note and asked to write a delivery note. The notes were evaluated for 15 key components.
Seventy-six percent (n = 25) of residents recorded less than 10 of 15 key components of a delivery note after a shoulder dystocia. The majority of residents (91%, 30/33) included the correct order of the maneuvers used during the delivery, but most did not note which shoulder was anterior (18%, 6/33) or how long the head-to-body interval was during delivery (45%, 15/33).
Residents' delivery notes after a shoulder dystocia simulation often lacked critical elements. Training in documentation is needed in residency training. The addition of the delivery note and feedback regarding the note represents a simple innovation in this teaching scenario that may help identify deficiencies in documentation.
III
使用分娩模拟器描述和分析肩难产演练后的分娩记录
来自2个大学培训项目的33名住院医师在产科分娩模拟器上进行标准化肩难产场景测试。分娩完成后，告知每位住院医师婴儿的阿氏评分和出生体重，并告知婴儿四肢活动正常。然后给住院医师一份空白病程记录，要求其撰写一份分娩记录。对这些记录进行15项关键内容的评估。
76%（n = 25）的住院医师在肩难产分娩记录中记录的15项关键内容少于10项。大多数住院医师（91%，30/33）记录了分娩过程中使用手法的正确顺序，但大多数人没有记录哪一侧肩部在前（18%，6/33）或分娩过程中头身间隔时间（45%，15/33）。
肩难产模拟后的住院医师分娩记录往往缺乏关键要素。住院医师培训中需要进行记录方面的培训。在这种教学场景中增加分娩记录及关于记录的反馈是一项简单的创新，可能有助于发现记录方面的不足。
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