Apgar score documentation

[narcusprince]

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Do you guys document the Apgar scores on your anesthesia record? And if you document scores that are low 0-3 any intervention made. Apgar scores are the only scores we routinely document where we as anesthesia providers do not intervene. Everything else in the chart we react to. Is their medicolegal ramifications for documenting a low apgar and not intervening?

 

[TheLoneWolf]

Always

Do you guys document the Apgar scores on your anesthesia record? And if you document scores that are low 0-3 any intervention made. Apgar scores are the only scores we routinely document where we as anesthesia providers do not intervene. Everything else in the chart we react to. Is their and medicolegal ramifications for document a low apgar and not intervening?

Always documented these, even if uneventful. Had benefit of in house neonatology called to OR for scheduled high risk cases, so would always document their presence and interventions. When things go south on OB, I imagine every name on the chart is contacted. Cant cited any case law though.

 

[UrbanAchievers]

We don’t do any documentation of Apgar scores at my institution.

 

[anbuitachi]

Never. dont need nurse , ob, AND anesthesiologist to document the same thing

 

[Mman]

in our electronic record it is documented outside the anesthesia record. We do not make a separate text note of the apgar scores. No need as that info is already readily available.

 

[MoMoGesiologist]

I think u would find yourself in trouble if your documentation didn't match up with the people actually calculating the scores. You don't document the number of lap pads the surgeon uses. Why document what the OB nurse or peds is doing? What intervention are you doing for low scores when you are the mother's doctor?

 

[narcusprince]

I think u would find yourself in trouble if your documentation didn't match up with the people actually calculating the scores. You don't document the number of lap pads the surgeon uses. Why document what the OB nurse or peds is doing? What intervention are you doing for low scores when you are the mother's doctor?

Im discussing this point with my colleagues. Why document something you are not performing interventions on.

 

[dannyboy1]

Im discussing this point with my colleagues. Why document something you are not performing interventions on.

This. If the apgar score can be calculated that means the baby is out and is the patient of the neonatologist (who is thankfully present at every c/s at my institution).

 

[Ronin786]

Policy during residency was to document them, but I never did. Didn't make any sense to me when the nurse, OB, NICU and everybody in the room has it written somewhere. Plus it was one less thing I had to do.

 

[Urzuz]

Why do people always make more work for themselves?

No, I don't document it. I also don't document if the induction was smooth, if the tube is taped at 22cm "at the lip", if the extubation is smooth, if I scratch my balls during the case, etc. The amount of useless garbage that people fill their anesthesia records with baffles me.

 

[pgg]

Our EMR sucks and autocreates an empty entry for APGARs when we mark delivery time. It's smart enough to create work but not smart enough to do it.

 

[dchz]

Why document what the OB nurse or peds is doing?

I do it because some anesthesiologist in 1953 made up an acronym that became the subjective standard of neonatal assessment in the immediate post partum period (common, they ALL look PINK to me!!).... and she made it to fit her last name!!! How clever is that!?!??!!

I agree it has 0 medical value to us, but i do it as a shoutout to my girl Virginia.

 

[deleted50478]

Do you guys document the Apgar scores on your anesthesia record? And if you document scores that are low 0-3 any intervention made. Apgar scores are the only scores we routinely document where we as anesthesia providers do not intervene. Everything else in the chart we react to. Is their medicolegal ramifications for documenting a low apgar and not intervening?

I never document the Apgar score- mostly because a significant percentage of the time the Apgar is 10 and they say 9 because of superstition. Screw that, I’m not documenting your superstitious mumbo-jumbo.

 

[IMGASMD]

I never document the Apgar score- mostly because a significant percentage of the time the Apgar is 10 and they say 9 because of superstition. Screw that, I’m not documenting your superstitious mumbo-jumbo.

We never do. We have a few thousand deliveries a year. OB Nurse and NICU team do, we usually don’t get too much involved with the baby.

 

[narcusprince]

I never document the Apgar score- mostly because a significant percentage of the time the Apgar is 10 and they say 9 because of superstition. Screw that, I’m not documenting your superstitious mumbo-jumbo.

Your never think about this with normal numbers but after you have documented low apgars you think is this a process I need to be apart of unless asked for help. And warrants the thought should we be involved in documenting the process. What are the medicolegal possibilities of being involved?

 

[Mman]

I never document the Apgar score- mostly because a significant percentage of the time the Apgar is 10 and they say 9 because of superstition. Screw that, I’m not documenting your superstitious mumbo-jumbo.

Isn't it usually 9 because acrocyanosis is a normal finding in a newborn so you are almost always taking off 1 for color? Rare to have pink hands and feet immediately at birth.

 

[anbuitachi]

Why do people always make more work for themselves?

No, I don't document it. I also don't document if the induction was smooth, if the tube is taped at 22cm "at the lip", if the extubation is smooth, if I scratch my balls during the case, etc. The amount of useless garbage that people fill their anesthesia records with baffles me.

yea i dont quite understand why so many people document that their induction was smooth..

 

[deleted162650]

yea i dont quite understand why so many people document that their induction was smooth..

I write “SIVI” only to distinguish it from an “RSI”.

 

[DrZzZz]

yea i dont quite understand why so many people document that their induction was smooth..

Only time I write that is for a floor induction & intubation. Anecdotally, had a colleague induce a patient who was on death's doorstep. Tolerated their induction fine, colleague said they hung out with the patient for 5ish minutes after the intubation and their hemodynamics didn't budge. Patient died several hours later and medicine note claims patient was unstable immediately following the induction and intubation, placing some of the blame on my colleague. Nothing came of it in a legal sense. But I like to document that hemodynamics were smooth and, when applicable, I stuck around for a bit afterwards and made sure the team was comfortable with my departure. Just a little C.Y.A.

 

[anbuitachi]

Only time I write that is for a floor induction & intubation. Anecdotally, had a colleague induce a patient who was on death's doorstep. Tolerated their induction fine, colleague said they hung out with the patient for 5ish minutes after the intubation and their hemodynamics didn't budge. Patient died several hours later and medicine note claims patient was unstable immediately following the induction and intubation, placing some of the blame on my colleague. Nothing came of it in a legal sense. But I like to document that hemodynamics were smooth and, when applicable, I stuck around for a bit afterwards and made sure the team was comfortable with my departure. Just a little C.Y.A.

Understandable in situations with no EMR

 

[fakin' the funk]

Do you guys document the Apgar scores on your anesthesia record? And if you document scores that are low 0-3 any intervention made. Apgar scores are the only scores we routinely document where we as anesthesia providers do not intervene. Everything else in the chart we react to. Is their medicolegal ramifications for documenting a low apgar and not intervening?

No - not my patient

 

[Urzuz]

I write “SIVI” only to distinguish it from an “RSI”.

Why can't you have a SIVRSI??? 😀

 

[Mman]

But I like to document that hemodynamics were smooth and, when applicable, I stuck around for a bit afterwards and made sure the team was comfortable with my departure. Just a little C.Y.A.

Sure, but writing the word "smooth" in front of IV induction isn't covering anything. Actual documentation of vital signs at various times is the only thing saving your bacon in that setting.

 

[DrZzZz]

Sure, but writing the word "smooth" in front of IV induction isn't covering anything. Actual documentation of vital signs at various times is the only thing saving your bacon in that setting.

To addend my statement, I typically write in ballpark vitals in the note, ie. MAP ~65, HR 110-120, etc. What they were before induction, what they were post intubation. I don't actually write "smooth".

 

[deleted162650]

What if I write “Smoos, rike airprane”

A few of you know what I’m talkin’ about.

 

[Psai]

Why do people always make more work for themselves?

No, I don't document it. I also don't document if the induction was smooth, if the tube is taped at 22cm "at the lip", if the extubation is smooth, if I scratch my balls during the case, etc. The amount of useless garbage that people fill their anesthesia records with baffles me.

I like knpwing where the tube is taped before. Sometimes its too deep.