If it isn’t written down, then it didn’t happen: documentation in obstetric anaesthesia

Abstract

Accurate documentation in clinical medicine is vital for delivering safe patient care and essential for medicolegal protection. Several international medical governing bodies place accurate record keeping as one of the fundamental requirements for good clinical care. This edition of SAJAA features an article directly relevant to clinical documentation, specifically within obstetric anaesthesia. The study by Du Toit et al. is timely within the context of the medicolegal climate in South Africa.¹ While litigation occurs less frequently in anaesthesia than other specialities, medicolegal claims relating to obstetric anaesthesia are increasing in South Africa, and the nature of these claims is evolving. In the United Kingdom (UK), although claims related to obstetric anaesthesia have decreased, the pattern of litigation has changed with pain during caesarean section having replaced accidental awareness under general anaesthesia as the leading cause of successful litigation against obstetric anaesthetists.^2,3 Ensuring accurate clinical documentation, particularly recording standardised variables, can optimise clinical care and assist with managing potential medicolegal concerns, should they arise.