Other than having the neonatal resuscitation documented by a resident, the different level of training (attending or fellow) or discipline (nurse practitioner) of the primary documenter were also not significantly associated with the number of items documented per record.
The mean (SD) number of items documented in a record was 13.2 (3.5).
Figure 1 displays the number of items documented at each participating hospital as box and whisker plots.
Number of items documented per record: In each infant's record we assessed whether or not each Resuscitation Data Item was documented.
The description of resuscitation in each infant's record was evaluated for the presence of 29 Resuscitation Data Items and assigned a Number of items documented per record.
Our analysis suggests the number of items documented per record is institutionally related, which is likely due to policies, use of note templates, and institutional culture around documentation.
In our multiple linear regression model the number of items documented per record was related to the institution but not to infant characteristics.
The written comments were coded using a coding list based on the Calgary-Cambridge observation guide and enriched by additional communication items documented by the supervisors (Table 2).
For example in our completely adjusted model, the number of items documented per record in institution A was greater by 4.56 (95 % CI 3.46, 5.64) than at the reference institution F. In our adjusted model, documentation by a resident was associated with 1.87 (95 % CI 0.52, 3.24) more items documented per record.
Points range from 0 29 bAdjusted for all variables in table cStatistically significant characteristics In our completely adjusted model, only the institution and having a resident document the resuscitation were significantly associated with the number of items documented per record.
The infant characteristics including; birth weight, birth time, gestational age, presence of congenital anomaly, type of delivery, and multiparity were not significantly associated with the number of items documented per record.
