Shoulder dystocia documentation: an evaluation of a documentation training intervention.

Objective: To evaluate the quality and content of nurse and physician shoulder dystocia delivery documentation before and after MOREOB training in shoulder dystocia management skills and documentation. Methods: Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia between the years of 2000 and 2006 excluding the training year of 2003 were identified. The charts were evaluated for 14 key components derived from a validated instrument. The delivery notes were then scored based on these components by 2 separate investigators who were blinded to delivery note author, date, and patient identification to further quantify delivery record quality. Results: Approximately 346 charts were reviewed for physician and nurse delivery documentation. The average score for physician notes was 6 (maximum possible score of 14) both before and after the training intervention. The nurses' average score was 5 before and after the training intervention. Conclusions: Negligible improvement was observed in the content and quality of shoulder dystocia documentation before and after nurse and physician training.