Evaluation of Comprehensive Documentation After Obstetric Anal Sphincter Injury

INTRODUCTION AND HYPOTHESIS

The incidence of obstetric anal sphincter injuries (OASI) has increased in recent years, which may be due to improved recognition and documentation. There is limited evidence regarding the effects of thorough documentation of obstetric anal sphincter injury repairs on postpartum clinical outcomes. Our objectives were to (1) compare the incidence of perineal wound complications between documentation groups, (2) compare other adverse events, and (3) to describe factors associated with adequate documentation. We hypothesized that better documentation would be associated with improved clinical outcomes.

METHODS

This was a retrospective cohort study of 599 patients with OASI at a tertiary care referral center between January 2015 and December 2020. A priori definitions of documentation adequacy were utilized to stratify delivery notes. On the basis of these criteria, there were preferred, adequate, and inadequate documentation groups. Maternal characteristics, outcomes, and peripartum factors were compared between the groups.

RESULTS

There were no significant differences in clinical outcomes between the groups. A higher degree of perineal laceration (p < 0.001), greater blood loss (p = 0.002), and the need for repairs in the operating room (p = 0.019) were significant factors associated with adequate documentation. Clinicians who were comprehensive in their documentation were more likely to refer patients to Urogynecology (p < 0.001) and to add OASI to the electronic medical record problem list (p = 0.005).

CONCLUSIONS

While certain factors are associated with adequate documentation, this did not improve clinical outcomes for OASI and further research is warranted to explore the importance of medical documentation surrounding OASI.

Accuracy of obstetric laceration diagnoses in the electronic medical record

INTRODUCTION AND HYPOTHESIS

Patient safety data including rates of obstetric anal sphincter injury (OASI) are often derived from hospital discharge codes. With the transition to electronic medical records (EMRs), we hypothesized that electronic provider-entered delivery data would more accurately document obstetric perineal injury than traditional billing/diagnostic codes.

METHODS

We evaluated the accuracy of perineal laceration diagnoses after singleton vaginal deliveries during one calendar year at an American tertiary academic medical center. We reviewed the entire hospital chart to determine the most likely laceration diagnosis and compared that expert review diagnosis (ExpRD) with documentation in the EMR delivery summary (EDS) and ICD-9 diagnostic codes (IDCs).

RESULTS

We retrospectively selected 354 total delivery records. OASI complicated 56 of those. 303 records (86%) were coded identically by the EDS and IDCs. Diagnoses from the IDCs and the EDS were mostly correct compared with ExpRD (sensitivity = 96%, specificity = 100%). There was no systematic over- or under-diagnosis of OASI for either the EDS (p = 0.070) or the IDCs (p = 0.447). When considering all laceration types the EDS was correct for 21 (5.9%) lacerations that were incorrect according to the IDCs. Overall, the EDS was more accurate (p < 0.05) owing to errors in IDC minor laceration diagnoses.

CONCLUSIONS

Electronic medical record delivery summary data and EMR-derived diagnostic codes similarly characterize OASI. The EDS does not improve OASI reporting, but may be more accurate when considering all perineal lacerations. This assumes that providers have correctly identified and categorized the lacerations that they record in the EMR.