Defensibility Assessment of the Mother’s Medical Record
This tool has been tested by 6 organizations. As with any tool, and as more hospitals
use this tool, we will refine and update based on input from users. The findings from
the use of this tool should not be considered as the final decision about the defensibility of
care after an adverse event. As you know, there are many factors that may influence the
defense of care. The purpose of this tool is to determine if the changes implemented as part of
improving perinatal care are also improving the documentation of the care provided.
The goal is to improve the defensibility of the care through appropriate documentation.
Background
One of the goals for the Perinatal Collaborative is to ensure the defensibility of adverse
events. Reviews of medical malpractice claims report that documentation is often
lacking or incomplete. Many lacked documentation of the physician's recognition of the
risk factors involved.1 A review of claims from the Harvard system includes inadequate
documentation of care as a contributor to inadequate identification and response to fetal
distress.2
Appropriate documentation serves to ensure communication among providers and
continuity of care and it can be the only history of the care that was provided.
Incomplete or missing documentation makes it difficult to remember why decisions were
made and particular interventions applied.
Legible and complete documentation can often prevent an adverse outcome from
progressing to a malpractice claim.
In order to assist the perinatal teams to assess the quality of the documentation when
reviewing a medical record, we have developed the following tool. The purpose of this
tool is to provide reviewers with prompts that may help determine whether the
documentation in the medical record supports the care delivered or is a liability. This is
not all encompassing and represents general principles of loss prevention/risk
management. You may add items that in your judgment are critical in your
state/jurisdiction.
We recommend using this tool to review any medical record, not only if there has been
an adverse event.
_______________________
1Ogburn PL Jr, Julian TM, Brooker DC, Joseph MS, Butler JC, Williams PP, Anderson ML, Shepard AC, Ogburn SL, Preisler WC Jr,
et al., Perinatal medical negligence closed claims from the St. Paul Company, 1980-1982.
2 http://www.rmf.harvard.edu/files/documents/Forum_V21N1.pdf Accessed June 16, 2006
How to use this tool
In order to protect your findings from discovery, consider using this tool under your existing
quality improvement/peer review/risk management process. We suggest that you not record
the medical record number on these documents. Data should be aggregated and only
aggregated data should be reported on the IHI extranet. We suggest you also have your risk
manager and legal counsel review the tool prior to any data collection.
We suggest that you use this tool in the same manner as you use the IHI Perinatal
Trigger tool. Our suggestion is to use the same charts randomly selected for your harm
review (Perinatal Trigger Tool). Use the criteria listed for each record (Mother or Infant)
and determine if the expected elements of documentation are present. You will be
reviewing medical records in which no harm occurred. The goal is to review adherence
with desired practices of documentation in all charts. The random sampling
methodology will provide a representative sample. A registered nurse from the labor
and delivery area and the risk manager should review the records, discuss their
findings, and then make a final decision about the defensibility of each medical record
reviewed. As with the trigger tools, reviewers should not be reading the entire medical
record entry by entry, page by page but rather looking in the record to see if the items
listed are appropriately addressed on a consistent basis throughout the medical record.
Your judgment and experience will determine if the documentation in the medical record
can either assist or damage the defense of a case. In the event of serious harm, the
absence of any of these elements may result in an opportunity for the plaintiff attorney
to question the quality of care. Conversely, a complete and well documented medical
record demonstrates the meticulous manner of patient care.
We suggest a review of 20 couplet charts (total of 40) each month. Results posted
onthe extranet website by the 15th of the month following the completion of the
review.
1. Collect the 20 pairs of charts (20 for mother and 20 for baby).
2. Review all the charts using the elements in the enclosed tools for Mother and
Infant, regardless of the trigger tool results.
3. Indicate deficiencies in documentation.
4. Determine if the documentation of the care provided is complete, legible and
indicates teamwork and communication among the team.
5. Report on the extranet:
(https://www.ihi.org/extranetng/projecthome.aspx?contextGUID=fdb3913c-db0f481f-9553-1ee7ed523088)
a. Numerator: enter the number of records you have determined; based
on your standards and review, to be defensible.
b. Denominator: enter the total number of medical records reviewed.
c. The extranet will then calculate the percentage of records considered
defensible.
For the Mother
______Yes
______Yes
______Yes
______No
______No
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
Labor and Delivery
______Yes
______No
13. Plan of care is documented.
14. Nursing and physician/midwife documentation compliments
each other.
15. Mother and fetal vital signs are appropriately documented.
(Frequency of the documentation is consistent with policy guidelines
for fetal monitoring and epidurals and any post procedure
monitoring).
16. There is documentation in the medical record by healthcare
providers, during the course of the labor period, which is consistent
with any hospital policies in terms of the frequency of patient
checks, epidural insertion and patient monitoring, etc. These entries
also contain appropriate assessment notes and the patient’s
progress and any concerns by the provider.
17. There is documentation of any calls to members of the
healthcare team regarding a change in maternal or fetal status.
18. There is documentation that appropriate action was taken by
______Yes
______Yes
______No
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
Documentation In General for the Whole Patient
1. All entries are dated and timed.
2. All entries are signed or initialed. (If initialed a key is available to
determine the identity of the individual for each set of initials.)
3. All pages in the medical record contain the patient’s name and
correct identification information
4. Unused lines or spaces have a single line through them to
prevent late entries or additions to the record.
5. There is documentation that dictated notes are reviewed and
signed.
6. Entries by residents either notes or dictation are co-signed by
attending as required (ACGME)
N/A (Not Applicable) no residents on staff _________
7. There is no indication that the medical record has been altered
and sections of the record have not been removed.
8. Entries in the medical record are legible, have not been altered
nor are letters or numbers written over each other or obliterated to
correct errors.
9. Abbreviations on the “Do Not Use” list are not used by
employees, midwives, physicians or other healthcare providers.
10. Verbal orders are documented and authenticated within defined
time frame per hospital policy.
11. Notes are documented as if a patient will read the record. (Are
objective, factual and do not contain judgmental or subjective
comments.)
12. If a language barrier was identified, there is documentation that
steps were taken by healthcare team members to communicate on
an ongoing basis with the patient and written materials provided in
the patient’s preferred language.
N/A Not applicable ________
nursing staff if a resident or attending did not respond to a nurse’s
concern about the patient’s condition (i.e. chain of command policy
was carried out).
Fetal Monitoring
19. There is documentation of when the fetal monitor is applied to
the laboring patient and when it is removed and or restarted.
20. Electronic fetal monitor (EFM) strips and recorded ultrasound
images are retained for each patient. (EFM strips are retained per
policy of the hospital and can be provided if needed.)
21. EFM documentation is consistent with hospital policy to include
the frequency of patient assessments, any interventions performed,
medications administered or dosages of IV medications changed,
the presence of healthcare providers at the bedside, etc.)
22. Documentation of care in a spontaneous vaginal delivery is in
accordance with institutional policy. (Labor and Delivery form
documentation is complete.)
N/A Not a Vaginal delivery ____________
23. Indications, rationale and performance of procedures or
maneuvers selected for operative vaginal delivery are documented
in the medical record.
N/A Not an operative vaginal delivery ___________
24. Documentation of care in a cesarean section is in accordance
with institutional policy. (Indications and procedure are documented,
including the application of forceps and/or a vacuum).
N/A Not a cesarean section _________
25. For emergency situations – for example emergency c-section,
documentation provides a record of what took place, when, where,
and who was involved and the outcome. Decision to incision time
can be determined from this documentation.
N/A No emergency situations occurred ________
26. For an emergency c-section the time from incision to decision is
appropriate per hospital policy. (Should be no greater than 30
minutes or per hospital policy)
N/A Not an emergency c-section _________
26. Identification of the parent and infant is verified prior to
discharge and documented in the medical record. (Identification
bands may be retained, etc.)
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
______Yes
______No
_____Yes
______No
_____Yes
______No
_____Yes
______No
_____Yes
______No
Consents
27. General treatment consent is properly signed by all parties to
include date and time, etc., per the hospital form/policy.
28. Informed consent for the delivery is properly signed by all
parties to include date and time, etc. If patient was unable then
signature was obtained from legally responsible person.
29. Informed consent for any delivery or procedure includes
information about the proposed treatment, benefits and drawbacks,
alternatives, likelihood of success and problems related to recovery,
prior to the procedure/treatment.
Results
30. There is documentation in the medical record that critical
lab/test results have been reported to the appropriate healthcare
team members to include the time of notification.
Education and Discharge Instructions
31. Education of the mother regarding infant care is documented in
the medical record.
32. Education regarding infant care is documented in the medical
record for other caregivers if applicable.
N/A _____
33. Education regarding the mother’s self care and follow-up after
discharge is documented in the medical record. (Breast feeding,
wound care, etc.)
34. Written discharge instructions are provided and copies are
retained in the record to include acknowledgement of the
instructions having been provided to the patient.
Total Number of responses _____ Yes
_____ No
_____Yes
______No
_____Yes
______No
_____Yes
______No
_____Yes
______No
_____ N/A
Is this medical record defensible from a risk management perspective?
Based upon:
 the number of “Yes” responses, and
 documentation standards in your hospital
______Yes
______No