RESUMO
The practice of obstetrics is well-known as a medicolegal, high-risk profession. Poor charting is considered an area of serious deficiency for physicians and especially for obstetricians. We reviewed the charting practices of obstetricians in a level II community hospital. The traditional 1- and 5-minute Apgar scores were employed as the screening criteria. Apgar scores of 7 or lower at 5 minutes were used to identify charts considered vulnerable to litigious activity. Of 1437 deliveries, 115 charts with 5-minute Apgar scores of 7 or lower were reviewed. Traditional requirements for charting, eg, history and physical exams, admission notes and diagnoses were recorded fairly consistently. However, elements such as statements of judgment, autopsy reports, scalp pHs, and extended Apgar scores that would render a chart defensible were sorely lacking. Charting skills, not necessarily the quality of care, may render obstetricians medicolegally vulnerable.
