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Audit of Caesarean section Documentation

Author(s)
Jahan Ara Saeed Department of Gynae/Obs, Islamabad Medical and Dental College,Islamabad,Pakistan.
Abstract
Background: To study the standard of caesarean section surgical documentation Methods : In this retrospective study 30 consecutive cases who underwent cesarean section were studied. The surgical documentation was analyzed on 16 parameters under three major categories. Category 1 was regarding the personnel. This included the documentation of name of surgeon, assistant and anesthetist. Category 2 was surgical procedure giving detail about Status of uterine cavity, skin and uterine incision, uterine and skin closure, Venous thrombosis risk , blood loss and finally the instrument count, swab count and post op plan. Category 3 was regarding the baby gender , weight, Apgar score and cord pH. Results: There were deficiencies in the surgical detail documentation of caesarean section .The documentation of personnel was 95%.The surgical documentation regarding uterine cavity and blood loss during surgery were 90%.Documentation regarding swab and instrument count being complete was only in 25% of the cases. Post op plan was documented in only 60% of the cases. Notes regarding the newborn were insufficient. The documentation of baby gender, weight and Apgar score were 85%, 45% and 65% respectively. Conclusion: Caesarean section surgical documentation needs to meet international standard of minimal documentation. It is required to introduce a minimal standard surgical document to be attached in the notes of all patients undergoing caesarean section to be completed by the operating surgeon within 24 hrs of surgery.
Publication Details
Page(s) 136-138
DOI DOI not available
Published Journal: Journal of Rawalpindi Medical College, Volume: 20, Issue: 2, Year: 2016

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Keywords
Post operative, Documentation, Caesarean section
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