Medical Chart Review of the Apgar Score

The Apgar score is a standard measure used by healthcare practitioners when an infant is born. The results of the score have great significance and long term implications. Understanding how the scoring is done and who is qualified to do the scoring can provide helpful insight when reviewing a birth record and determining outcomes. Of course, there remain multiple controversies regarding the implications of a low or even high Apgar score. This article does not seek to parse those sides and arguments out. Rather, to provide insight as to how Apgar scores should be properly scored. Why? An improperly assigned Apgar score can falsely lead legal arguments down the wrong path.

An Apgar score should be assigned at one and five minutes of life. The one minute Apgar score is believed to be a reflection of how well the infant tolerated the birthing process. The five minute Apgar is used to show how well the infant is adjusting to extrauterine life. A score of 0 to 3 is critically low; 4-6 is fairly low and 8 or above is considered normal. If the five minute score is less than 7, NRP guidelines state that the assessment should be repeated every five minutes up to twenty minutes.

Of great importance is to note that if an infant appears critically low at birth, intervention should not wait until the one minute Apgar is assigned. Intervention should begin immediately. Therefore, when reviewing a chart of an infant where intervention has been necessitated, it is important to keep in mind that subsequent scores are including intervention. So, a five minute Apgar score that involves intervention should be reviewed in that light. It is important not to equate the Apgar score of a spontaneously breathing infant with one that requires intervention. This is because many of the elements that have contributed to their score have been influenced by intervention. There is discussion within the medical community to change the Apgar scoring chart so that it becomes an extended Apgar score report that includes resuscitative interventions.

A resuscitation effort that has low scores should include documentation from team members regarding the infant’s initial appearance, Apgar score assigned, interventions initiated and response to intervention. Further, look for an Apgar chart where practitioners qualify their specific assignments for each component. A birth record review should involve a review of the Apgar assigned with the narrative note that includes a description of the infant’s appearance. If an Apgar score does not appear to match the appearance of the infant in the narrative note, an explanation should be sought in the medical record. An infant who is described as floppy, cyanotic, no heart rate and no respirations should not have an Apgar of 3. Documentation to support scoring of this nature should be sought out. It should also include review of the birth record that identifies the resuscitative efforts with correlating Apgar assignment.

For more information on Apgar scores and review of birth records, please contact our office.

Reference:

American Academy of Pediatrics and American Heart Association. Neonatal Resuscitation., 2000. American Academy of Pediatrics. The Apgar Score. Pediatrics, 2006 Apr;117(4): 1444-14447.