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首页> 外文期刊>The HIM journal >Documentation of instrumental vaginal deliveries: The benefits of a pro forma
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Documentation of instrumental vaginal deliveries: The benefits of a pro forma

机译：阴道阴道分娩的文件：备考的好处

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Background: Instrumental vaginal deliveries (IVDs) account for approximately 11% of births in Australia. Complications resulting from IVD can occasionally be the subject of litigation. The Royal College of Obstetricians and Gynaecologists suggests a standardised pro forma in their guidelines as an aid to accurate and complete IVD documentation. Many units, including ours, use less structured reporting, which is probably also less adequate. Aim: To assess whether the introduction of a dedicated IVD form improves the quality of IVD documentation. Method: Analysis of the quality of IVD documentation before and after the implementation of a new dedicated IVD form. A survey to evaluate clinicians’ opinion on the new standardised form. Results: Significant improvement was found in documentation of key information including the documentation of caput (p < 0.05), type of instrument, number of ventouse cup detachments, moulding of specific sutures, abdominal palpation (number of fifths of foetal head palpable), liquor colour and total time of instrument application (p < 0.001). A majority of clinicians believed the form to be beneficial in terms of completeness and that it reduced the amount of time required for documentation. Conclusions: IVD documentation is enhanced by the use of a dedicated form. Clinical judgement may also be enhanced by the discipline involved in the formal assessment required by the form.
机译：背景：阴道分娩（IVD）约占澳大利亚分娩的11％。 IVD引起的并发症有时可能成为诉讼的主题。皇家妇产科学院在其指南中建议采用标准化的备考形式，以帮助准确和完整的IVD​​文档。许多单位，包括我们的单位，使用的结构化报告较少，可能还不够充分。目的：评估引入专用的体外诊断表格是否能提高体外诊断文档的质量。方法：在实施新的专用IVD表格前后，对IVD文档的质量进行分析。一项旨在评估临床医生对新标准化表格的意见的调查。结果：在关键信息的文档中发现了显着改善，这些文档包括：帽盖（p <0.05），仪器类型，气腹杯脱离次数，特定缝合线的成型，腹部触诊（可触及的胎头的五分之一数），酒颜色和仪器使用的总时间（p <0.001）。大多数临床医生认为该表格在完整性方面是有益的，并减少了记录所需的时间。结论：通过使用专用表格可以增强IVD文档。表格所要求的正式评估所涉及的学科也可以加强临床判断。

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