electronic-Perak Medical Journal Vol 2 No 1 August 2022
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ORIGINAL ARTICLE
A Retrospective Study on Complete Documentation of Obstetric Anal Sphincter Injuries Proformas in Hospital Raja Permaisuri Bainun, Ipoh
Ng Jun Jiet1*, Thuvina Aruku Naidu2, Parveena Soorianarayanan2, Aruku Naidu Apana1
1Department of Obstetrics and Gynaecology, Hospital Raja Permaisuri Bainun, Ministry of Health MALAYSIA
2Newcastle University Medicine Malaysia, Johor, MALAYSIA
One of the issues highlighted was poor and incomplete documentation. This may reflect poor adherence to institutional policies, substandard patient care and suboptimal medical record keeping. Patient can use this to support allegations of negligence5.
According to the Green-top guideline No.29 by RCOG, there should be 100% evidence of adequate documentation of systemic examination before OASIS repair, type of analgesia used, suture materials, method of repair as well as postoperative advice and follow-up appointments3. Pictorial diagram and drawing are encouraged to illustrate the extent of injury and the anatomical structures involved. All of these criteria must be included in the OASIS proformas.
There is an abundance of literature on the prevalence, risk factors and management of OASIS. However, not many emphasize on the documentation of OASIS. Therefore HRPB has implemented a standard OASIS reporting proforma since 2018 (Figure 3). All documents are duplicated and stored in both patient folders and a separate folder for audit purposes.
The aim of our audit is to evaluate the rate of complete documentation of OASIS proformas in HRPB.
INTRODUCTION
Obstetric anal sphincter injuries (OASIS) is a term used to describe third and fourth degree perineal trauma sustained during childbirth. It is the commonest cause of anal incontinence in women of reproductive age1. OASIS may affect women’s physical, psychological, social and sexual well-being if it is not diagnosed and managed appropriately.
The prevalence of OASIS differs from place and time. The incidence of OASIS in Hospital Raja Permaisuri Bainun (HRPB), Ipoh ranged from 0.3–0.9% between the year 2016 and 2020 (Figure 1)2. Incidence of OASIS has been observed to be higher in the presence of certain risk factors such as prolonged second stage of labour, Asian ethnicity, nulliparity, birthweight greater than 4 kg, occcipito-posterior position and instrumental delivery3.
The Sultan classification system adopted by the Royal College of Obstetrics and Gynaecology (RCOG) is the most widely accepted OASIS classification. Four grades of severity are acknowledged in this classification (Figure 2).
There has been a steady increase in litigation related to OASIS in recent years. In the United Kingdom, there has been 488 claims related to OASIS between the years 2000 and 2010, and £31.2 million were paid4.
Keywords: complete documentation, OASIS proformas, anal sphincter injury, perineal trauma, anal incontinence Citation: Ng JJ, Aruku Naidu T, Soorianarayanan P, Apana AN. A Retrospective Study on Complete Documentation of Obstetric Anal Sphincter Injuries Proformas in Hospital Raja Permaisuri Bainun, Ipoh. e-PMJ, Volume 2(1), 2022
*Correspondence to:
Ng Jun Jiet, (MD, MRCOG), [email protected]
Received: 07 December 2021 Accepted: 30 May 2022
Copyright: © 2022 Ng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interest: The authors have declared that no competing interests exist.
ABSTRACT
INTRODUCTION
Documentation is an important part of obstetric anal sphincter injuries (OASIS) management that is often neglected, leading to suboptimal patient care and medical litigation. The aim of our audit is to evaluate and compare the documentation of OASIS proformas in Hospital Raja Permaisuri Bainun (HRPB) between the year 2018 and 2020.
METHODS
A retrospective review of 102 OASIS proformas between the year 2018 and 2020. Data was analysed using Microsoft Excel and presented using descriptive statistics.
RESULTS
The rate of OASIS proformas that are completely filled was low. Out of the 3 years, none successfully achieved the target level of performance.
CONCLUSION
Healthcare providers should be aware of the importance of documentation in the management of OASIS.
Measures should be taken to ensure complete documentation of OASIS proformas.
electronic-Perak Medical Journal Vol 2 No 1 August 2022
2 Figure 1: Incidence of OASIS in HRPB, Ipoh across the years 2016–2020
Figure 2: Sultan's classification of obstetrics anal sphincter injuries (OASIS)
Figure 3: Hospital Raja Permaisuri Bainun OASIS proformas
2016 2017 2018 2019 2020
Incidence of OASIS 0.30% 0.60% 0.80% 0.90% 0.50%
0.30%
0.60%
0.80%
0.90%
0.50%
0.00%
0.10%
0.20%
0.30%
0.40%
0.50%
0.60%
0.70%
0.80%
0.90%
1.00%
First-degree tear Injury to perineal skin and / or vaginal mucosa.
Second-degree tear Injury to perineum involving perineal muscles but not involving the anal sphincter.
Third-degree tear Injury to perineum involving the anal sphincter complex.
Grade 3a tear Less than 50% of external anal sphincter (EAS) thickness torn.
Grade 3b tear More than 50% of EAS thickness torn.
Grade 3c tear Both EAS and internal anal sphincter (IAS) torn.
Fourth-degree tear Injury to perineum involving the anal sphincter complex and anorectal mucosa.
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In 2018, 33 forms were analysed. 9 forms had 3 or more sections completed. Of all the sections, Section 3 had the highest completeness rate (27 completed forms), followed by Section 4 (26 completed forms), Section 1 (14 completed forms) and Section 2 (4 completed forms).
In 2019, 47 forms were analysed. Seven forms had 3 or more sections completed. Section 4 had the highest completeness rate (43 completed forms), followed by Section 3 (40 completed forms), Section 1 (9 completed forms) and Section 2 (0 completed form).
In 2020, 22 forms were analysed. Seven forms had 3 or more sections completed. Sections 3 and 4 had the highest completeness rate (20 completed forms each), followed by Section 1 (6 completed forms) and Section 2 (4 completed forms) (Table 2).
Table 2: Most and least filled in section over 3 years Year Number of
records
Most filled in
Least filled in
2018 33 Section 3 Section 2
2019 47 Section 4 Section 2
2020 22 Section 3
and 4 Section 2
Figure 4: Comparison between complete documentation of OASIS proformas over 3 years.
DISCUSSION
Medical documentation is important for several key purposes:
good patient care, staff communication, legal documentation, billing and imbursement, research and quality management6.It protects the healthcare providers as well as the patients.
Among ways to help clinicians to improve their documentation skills are standardisation, regular review and audit, peer support and continued education. HRPB have standardised the documentation of OASIS by implementing OASIS proformas7. However, this audit showed that the rate of OASIS proformas that are completely filled was low. Out of the 3 years, none has successfully achieved the target level of performance. Root cause analysis showed that among the reasons of incomplete documentation were insufficient time, high workload, not familiar with OASIS proformas and unaware of the importance of documentation.
MATERIALS & METHODS
This is an internal audit carried out by consultants and specialists in the department of Obsterics and Gynaecology in HRPB. We have conducted our audit according to the audit cycle: audit topic identification, setting the audit standard, compare performance with standard and implement changes. A total of 102 OASIS proformas over three years were reviewed and analysed.
The proformas consists of four sections:
Section 1: Demographics and case identification Section 2: OASIS repair management
Section 3: OASIS post-repair management Section 4: Signing off
The standard of this audit was based on Green-top guideline No.29 by RCOG “100% evidence of adequate documentation of systemic examination before OASIS repair, type of analgesia used, suture materials, method of repair as well as postoperative advice and follow-up appointments”3. In order for the OASIS proformas to be considered complete, 3 or more sections need to be filled up.
All data used in this study was tabulated on Microsoft Excel for analysis. Descriptive data analysis was used to measure the rate of completeness of OASIS proformas.
RESULTS
Analysis on complete documentation of OASIS proformas in the Department of Obstetrics and Gynaecology (O&G) HRPB was done according to year and section.
Table 1: Achieved target of O&G department Hospital Raja Permaisuri Bainun over 3 years
Criteria
Target level performance
(%)
Achieved target
(%)
Achieved criteria
3 or more sections complete
in the OASIS form in 2018 100 27 No
3 or more sections complete
in the OASIS form in 2019 100 15 No
3 or more sections complete
in the OASIS form in 2020 100 32 No
By year
Out of the 3 years, none successfully achieved the target level of performance. In 2018, 9 out of 33 forms were complete (27%). In 2019, 7 out of 47 forms were complete (15%). In 2020, 7 out of 22 forms were complete (32%) (Table 1).
The year 2019 is the year with the most incomplete OASIS proformas, this may have been attributed to the intake of new staff and the lack of awareness of the importance of proper documentation among the new staff.
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REFERENCES
1. Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D, Zamora J et al. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. Eur J Obstet Gynecol Reprod Biol.
2020;252:303-312.
2. Aruku Naidu. Hospital Raja Permaisuri Bainun labour room obstetric anal sphincter injuries (OASIS) census. (Unpublished raw data) 3. Royal College of Obstetrics & Gynaecology.The Management of Third-
and Fourth-Degree Perineal Tears. London. Green-top Guideline No 29. London 2015.
4. Sultan AH, Ritchie QC A, Mooney G. Obstetric anal sphincter injuries:
Review of recent medico-legal aspects. Clinical Risk. 2016;22:57-60.
5. Gong M, Mann GK, Koenig N, Geoffrion R. Documenting Perineal and Obstetrical Anal Sphincter Injury Care at Childbirth: A Cross-Sectional Study. J Obstet Gynaecol Can. 2021;43:1164-1169.
6. Thomas J. Medical records and issues in negligence. Indian J Urol.
2009;25:384-388.
7. Glen P, Earl N, Gooding F, et al. Simple interventions can greatly improve clinical documentation: a quality improvement project of record keeping on the surgical wards at a district general hospital BMJ Open Quality 2015:1-4
8. Panigrahy R, Welsh J, MacKenzie F, Owen P; Perinatal Effectiveness Committee in Glasgow (PEC). A complete audit cycle of management of third/fourth degree perineal tears. J Obstet Gynaecol.
2008;28(3):305-309.
Action plans and recommendations to improve the documentation of OASIS proformas are:
1. Making complete documentation of OASIS proformas as one of the department key performance index (KPI).
2. OASIS proformas need to be counterchecked and countersigned by specialist after being filled.
3. Computerised electronic OASIS proformas where compulsory columns need to be filled in before able to sign off. With the help of computer, OASIS database can be created.
4. Reminders are to be put up in the operation theatre to remind healthcare providers on complete documentation of OASIS proformas.
5. Regular continuous medical education and workshop on OASIS, so that healthcare providers are familiar with OASIS proformas and aware of the importance of medical documentation.
6. Regular audits are to be conducted using the Plan-Do- Check-Act (PCDA) cycle. After changes have been implemented, reaudit need to be carried out to ensure the standard is achieved.
LIMITATIONS
As this is the first audit on complete documentation of OASIS proformas in HRPB, there is no local data from previous audit to compare with. Literatures on documentation of OASIS are sparse. Compared to an OASIS management audit by Panigraphy R et al., which reported 73% completeness rate of OASIS proformas, HPRB completeness rate is suboptimal8. The strength of this audit is that there was no missing OASIS proformas throughout 3 years with 0% dropout rate .
CONCLUSION
Clear and concise medical record documentation is critical to providing patients with quality care, mitigating malpractice risks, and helping healthcare providers evaluate and plan the patient’s treatment and maintain the continuum of care. We hope that this audit can raise the awareness among healthcare providers on the importance of documentation as part of OASIS management. Action plans will be implemented in a stepwise manner and a reaudit will be carried out. Every hospital should have a standard OASIS proforma and audit should be done regularly to ensure complete documentation and adherence to clinical standards.
ACKNOWLEDGEMENTS
We would like to thank the Director General of Health Malaysia for his permission to publish this article. We wish to thank Dr Jennifer King MBBS, FRANZCOG CU for sharing the OASIS proforma.
