ORIGINAL  
Niger J Paed 2015; 42 (2):121 –125  
Onyiriuka AN  
Sadoh WE  
Ursula Kuhnle-Krahl  
Elusiyan JBE  
Audit of clinical documentation of  
external genitalia examination find-  
ings in the newborn: The Benin-city  
experience  
DOI:http://dx.doi.org/10.4314/njp.v42i2.10  
Accepted: 7th January 2015  
Abstract: Background: Over the  
years, poor medical documenta-  
tion is a well known phenomenon  
in medical practice but the mag-  
nitude of the problem in our set-  
ting has not been defined.  
Objective: To assess the overall  
frequency of missed detection of  
anomalies of external genitalia  
following the routine newborn  
physical examination and to de-  
scribe the general pattern of its  
documentation.  
to the fact that the previous exami-  
nation findings documented in the  
case files were being assessed dur-  
ing this study.  
Onyiriuka AN (  
Sadoh WE  
)
Department of Child Health,  
Results: Of the 915 infants, 19  
(2.1%; 95% CI= 1.2-3.0) had  
anomaly of the external genitalia  
at birth. The overall frequency of  
missed diagnosis of external geni-  
tal anomalies was 68.4% with un-  
descended testes (UDT) being the  
most frequently missed. The level  
of documentation of the findings  
of the external genital examination  
was poor in both hospitals. Com-  
bining the two hospitals, the exter-  
nal genital examination findings  
were not documented in 76.1% of  
case files.  
Conclusions: The routine newborn  
examination as currently practiced  
in the two hospitals was weak in  
detecting external genital anoma-  
lies. Poor documentation of the  
external genital findings is a com-  
mon occurrence in the setting  
where we practice, irrespective of  
whether the health institution is  
tertiary or secondary.  
University of Benin Teaching Hospital,  
PMB 1111,Benin City, Nigeria.  
Email: alpndiony@yahoo.com  
Ursula Kuhnle-Krahl  
Hormon- and Diabetes Center,  
Starnberger Str., 82131, Gauting,  
Germany.  
Elusiyan JBE  
Department of Paediatrics  
and Child Health,  
Obafemi Awolowo University  
Teaching Hospital,  
Ile Ife, Nigeria.  
Methods: In this hospital-based  
descriptive cross-sectional study,  
9
15 full-term newborn infants in  
an open population survey were  
systematically screened for  
anomalies of the external genita-  
lia, using a checklist derived by  
modifying parameters in the  
Prader scoring system and the  
External masculinization score  
charts. The pattern of documenta-  
tion was assessed in 915 case  
files. The findings of the research-  
ers were then compared to those  
previously documented by the  
attending physician/midwife. The  
study was conducted in two Nige-  
rian hospitals (University of  
Key words: Audit, clinical docu-  
mentation, external genitalia  
anomalies, missed diagnosis, rou-  
tine newborn examination.  
Benin Teaching Hospital and St  
Philomena Catholic Hospital) in  
Benin City. All members of staff  
of the two hospitals were blinded  
Introduction  
ing procedure. The aims of the procedure include (i) to  
detect congenital anomalies (ii) to detect clinical condi-  
tions that might have an adverse effect on the health of  
the infant and institute a plan of management and (iii) to  
impact advice and/or reassurance to parents. Although  
there is a general feeling that missed diagnosis is com-  
mon, with many clinicians giving anecdotal accounts of  
their own experiences, there is a relative lack of studies  
on the subject of misdiagnosis. Over the years, poor  
medical documentation is a well-known phenomenon in  
medical practice but the magnitude of the problem,  
particularly in developing countries, has not been  
The routine examination of the newborn refers to the  
examination that is carried out between 6 and 72 hours  
after birth by an appropriately trained healthcare profes-  
1
sional and with the parents’ consent . The National In-  
stitute for Health and Care Excellence (NICE) guideline  
recommends that such examination findings be recorded  
in the postnatal care plan and in the personal child health  
1
record . However, the application of this guideline has  
not received sufficient attention in Nigeria. In one sense,  
the newborn physical examination represents a screen-  
1
22  
defined. Apart from occasional medical audit, studies  
focusing on this issue are scarce. Patients’ records are  
among the most basic of clinical tools and are involved  
in almost all consultations and interactions with patients  
at all levels. They are to give a clear and accurate picture  
of the patient’s clinical status at birth (the external geni-  
talia inclusive). They help doctors to communicate with  
other doctors, with other healthcare professionals and  
with themselves. Clinical records are essential to ensure  
that the individual’s assessed needs are met, comprehen-  
sively as well as timely. The record is the clinician’s  
main defense, if his assessments or decisions are ever  
preterm neonates and neonates delivered outside the  
study hospitals were excluded.  
The study was approved by the Ethics and Research  
Committee of the University of Benin Teaching Hospi-  
tal. Permission was obtained from the authorities of the  
two hospitals. Consent was obtained for examination of  
the newborn infants from their mothers, after informing  
them of specific objectives of the study.  
A newborn external genitalia examination checklis10t  
combining parameters in the Prader Scoring system  
11  
and External Masculinization Score (EMS) charts was  
developed by the researchers to assist in assessing the  
reliability of the routine newborn examination in detect-  
ing anomalies of the external genitalia. Research assis-  
tants (a female nurse and a doctor) were trained for the  
study. The research assistant (a medical doctor) was  
trained on the “two-handed technique” for the examina-  
tion of the testis as well as on the technique for measure-  
ment of the penile length. The female nurse was trained  
on the method of holding and positioning the newborn  
infant for examination of the external genitalia and she  
also acted as a chaperone during the newborn physical  
examination. The stretched penile length of the infant  
was also measured. The rank of the health professional  
who performed the routine newborn examination was  
also documented.  
2
scrutinized. The quality of the case record2 will be as-  
sumed to reflect the quality of care received .  
An extensive search of the literature did not reveal any  
Nigerian study that has examined the quality and docu-  
mentation of routine newborn examination and its reli-  
ability in detecting anomalies of the external genitalia.  
Such documentation has the potential of enhancing col-  
lection and gathering of data on anomalies of the exter-  
nal genitalia. More importantly, it could contribute to  
saving the lives of such neonates which will ultimately  
4
reduce infant mortality as envisaged in MDG 4. In de-  
veloped countries where healthcare systems are strong,  
the standard of record-keeping in health institutions  
have been variously criticized by public bodies and offi-  
5
-9  
cial inquiries into deficiencies of care . Given that  
healthcare systems are generally weak in developing  
countries, the level of record-keeping in these countries  
is likely to be poorer compared with developed coun-  
tries. The above factors prompted the present study. The  
purpose of this study was to assess the overall frequency  
of missed detection of anomalies of external genitalia  
following a routine newborn physical examination and  
to describe the general pattern of documentation of its  
findings.  
The researchers assessed the physical examination find-  
ings which have been previously documented by the  
attending physician/midwife in the case file of each in-  
fant and compared these with researchers’ own findings  
on direct physical examination of the external genitalia  
of the newborn, using the checklist as a guide. The  
phrase ‘marked good’ refers to situations where the  
symbol “ was placed beside the area for documenta-  
tion of the external genitalia physical examination find-  
ing. The attending physicians/midwives were not aware  
that the previous documentation in the case file was be-  
ing assessed in this study. Before commencement of  
data collection, the authors and the assistants practiced  
with the checklist until their documentation for each  
baby reached agreement. The examination took place in  
the labour/postnatal ward at room temperature with the  
neonate lying in supine position. The testicular examina-  
tion of the infant involved a two-handed technique. The  
examining hand is gently swept along the inguinal canal,  
starting at the superior-lateral extent of inguinal canal. A  
true undescended or inguinal testicle will be felt to  
“pop” under the examiner’s fingers during this maneu-  
ver. A retractile testicle will be felt by the opposite hand  
Subjects and methods  
The study was conducted in two hospitals in Benin City,  
namely, the University of Benin Teaching Hospital  
(
UBTH), a tertiary healthcare level institution and St  
Philomena Catholic Hospital (SPCH), a secondary  
healthcare level institution. SPCH is located at the cen-  
tre of Benin City and ranks second among maternity  
units in Benin City. As a policy, in both hospitals,  
mothers usually stay for 2-3 days before discharge,  
forming the basis for the selection of these two hospitals  
for the study. This ensured availability of the newborn  
infants for physical examination in the first 72 hours of  
life.  
1
2
as it is manipulated into the scrotum. The position of  
the testis was recorded after its manipulation to the most  
distal position along the normal pathway of anatomical  
descent without forced traction. In this study, the posi-  
tion of the each testis was categorized into two major  
group as normal (if they were either normal scrotal or  
normal retractile) or undescended. The undescended  
group was sub-classified into prescrotal (if they were  
high scrotal or suprascrotal), inguinal or non-palpable  
Study population  
Nine hundred and fifteen (915) consecutively live-born  
term neonates aged between 6 and 72 hours whose par-  
ents gave consent for the newborn physical examination  
and who were delivered in the study hospitals during the  
study period were recruited into the study. The case files  
1
3
testes. In female newborns, the external genitalia (labia,  
clitoris, urethral opening) were inspected as recom-  
(
915) were also assessed. All still-born neonates and all  
1
23  
1
4
mended by Scanlon et al.  
The presence of a minor  
sis was 68.4% (13/19).The overall prevalence of exter-  
nal genital anomalies was 2.1% (19/915); 95% CI= 1.2-  
3.0). As shown in Table 2, undescended testes (UDT)  
was the most frequently missed developmental anomaly  
of the external genitalia following a routine newborn  
examination. Of the 9 cases in which the diagnosis of  
undescended testes was missed, 5 occurred in UBTH  
while 4 occurred in SPCH. Four (2 in UBTH and 2 in  
SPCH) cases of hypospadias were missed. However,  
the frequency of “some documentation” was 3 times  
higher in UBTH than SPCH.  
abnormality such as hymenal tag (which protrudes from  
the floor of the vagina) was examined for. Where ambi-  
guity of the external genitalia was present, i1ts0 degree  
was assessed, using the Prader Scoring System.  
All the members of staff were blinded to the fact that the  
previous examination findings documented in the case  
files would be assessed in this study. Each of the parents  
was informed of the findings of the physical examina-  
tion of their baby. Any anomaly detected was discussed  
with the parents including available management mo-  
dalities and referrals. Each study subject was treated as  
deemed fit, depending on the infant’s clinical condition.  
Other congenital anomalies, such as the patency and  
location of the anus were sought after detection of a  
genital anomaly.  
Table 1: Comparison of pattern of documentation of the exter-  
nal genitalia findings in the two hospitals following routine  
newborn examination.  
*UBTH = University of Benin Teaching Hospital (Tertiary healthcare  
Pattern of docu-  
mentation of  
external genitalia  
examination  
findings  
UBTH*  
No (%)  
SPCH**  
No (%)  
Odds ratio  
(UBTH vs  
SPCH)  
UBTH plus  
SPCH  
No (%)  
Statistical analysis  
Documented as no  
abnormality  
detected (NAD)  
The statistical analysis was performed using the SPSS  
software package version 15.0 (SPSS, Inc. Chicago, IL,  
USA). Descriptive statistics such as frequencies, means,  
ratios, confidence intervals, odds ratios and percentages  
were used in describing all the variables.  
42 (7.7)  
30(8.2)  
0.9  
72(7.9)  
Marked ‘’  
With some written  
Documentation  
67(12.2)  
31 (5.6)  
42(11.5)  
7(1.9)  
1.07  
3.06  
109(11.9)  
38(4.1)  
Without any docu-  
mentation  
409(74.5)  
287(78.4)  
0.80  
696(76.1)  
at all  
Total  
549(100.0)  
366(100.0)  
915(100.0)  
Results  
institution)  
**SPCH = St Philomena Catholic Hospital (Secondary healthcare  
During the four-month period (October, 2013 to Janu-  
ary, 2014) covered by the study, there were 612 and 410  
deliveries at the UBTH and SPCH respectively, corre-  
sponding to a total of 1,022 deliveries. As a result of  
multiple births, the total number of babies were 627 and  
institution).  
Table 2: Frequency of missed diagnosis of external genital  
anomaly during routine newborn examination  
External genital anom- No missed Frequency 95% CI  
aly  
4
18 in UBTH and SPCH, respectively. There were two  
(%)  
stillbirths in UBTH and one in SPCH. The total number  
of live-born babies in the two hospitals was 1,042 (530  
males and 512 females); giving a male-to-female ratio of  
Undescended testis  
(n=11)  
Hypospadias (n=6)  
Ambiguous genitalia  
9
81.8  
81.2-81.9  
66.5-66.9  
4
0
66.7  
0.0  
1
:1. One hundred and twenty seven (12.2%) of the 1,042  
infants were preterm (76 in UBTH and 51 in SPCH).  
Thus, the newborns analyzed for the study consisted of  
(n=2)  
9
15 (465 males and 450 females) full-term infants. The  
case files of 915 infants were reviewed. Excluding cases  
written no abnormality detected (NAD) or marked with  
the symbol “”, documentation concerning the external  
genitalia was done in 5.6% (31/549) of cases in UBTH  
and in 1.9% (7/366) of cases in SPCH; Odds ratio 3.06  
Discussion  
In the two hospitals studied, a poor pattern of documen-  
tation of the findings of the external genital examination  
was observed, suggesting that it is a common problem.  
It might also mean that the status of the external genita-  
lia of these babies were not assessed, resulting in lack of  
documentation. Whether the hospital was a tertiary- or  
secondary-healthcare institution did not appear to have a  
significant influence on the rate of poor documentation.  
Previous studies from developed countries with well  
established healthcare systems have reported a similar  
observation, sugges1t4i,n15g that it is a widespread problem  
(
Table 1). In addition, Table 1 shows that documenta-  
tion of the findings of external genital examination was  
poor in both the tertiary (UBTH) and the secondary  
(
SPCH) healthcare institutions. All the cases with some  
written documentation were done by physicians and  
these were infants with birth asphyxia, meconium aspi-  
ration syndrome, respiratory distress and infants of dia-  
betic mother requiring admission into the Special Care  
Baby Unit. There was no significant difference between  
doctors and midwives in terms of other patterns of docu-  
mentation in both hospitals. Of 219 cases documented  
on, anomalies were found in 13(5.9%).Anomalies were  
found in 6(0.9%) of 696 cases without any documenta-  
tion at all. Thus, the overall frequency of missed diagno-  
in clinical practice.  
clinical findings, this level of clinical practice falls short  
of the NICE recommendations and therefore, needs to  
be improved upon. The phenomenon of incomplete  
documentation in patients’ clinical records may have far  
With regard to documentation of  
1
1
24  
-
reaching consequences on the health institution (e.g.,  
examination of the external genitalia by the healthcare  
professionals. Th1is view is in keeping with the observa-  
litigation, lack of or inadequate epidemiological data),  
the healthcare provider (e.g., litigation, misdiagnosis,  
poor communication between physicians and other  
healthcare practitioners) and the children (e.g., improper  
or delayed treatment, long-term complications like infer-  
tility and testicular cancer in cryptorchidism, death in  
cases of unrecognized congenital adrenal hypoplasia). It  
is noteworthy that a diagnosis of acqu1i7r,e2d1,22 cryp-  
2
tion by Shapiro. The high rate of missed diagnosis may  
be a reflection that healthcare professionals tend to skip  
examination of the external genitalia. Such tendency in  
our clinical practice may be related to our local culture  
which discourages discussions on issues concerning the  
external genitalia. In literature, this fact was alluded to  
3
by Yarhere and Ahmed. They stated that sexual issues  
3
torchidism (a well recognized phenomenon  
) can  
are taboo subjects in many societies. It may also relate  
only be made if a previous documentation of the pres-  
ence of testis in the scrotal sac is available, further em-  
phasizing the importance of clinical documentation of  
newborn external genital examination findings.For these  
reasons, every health institution should ensure accurate  
and complete documentation of the clinical findings at  
all times, irrespective of the status of the healthcare  
practitioner who is involved. This is also important in  
avoiding litigation as more people become aware of  
their rights with regard to healthcare practice. For exam-  
ple, delayed or no treatment in cases of cryptorchidism  
with the attendant potential complications of impaired  
male fertility and testicular cancer later in life.  
to laziness on the part of the healthcare practitioner. One  
way of tackling the problem of missed diagnosis is by  
developing and popularizing a standardized method of  
examination of the external genitalia during routine  
newborn examination. The method could then be ex-  
tended to our rural healthcare facilities, thereby promot-  
ing referral of neonates with anomalies of external geni-  
talia to the tertiary healthcare hospitals. Data from our  
study have the potential of forming the basis for inter-  
vention strategies aimed at improving the quality of  
postnatal care and the general standard of practice, in-  
cluding documentation of clinical findings.  
Data from the present study, confirm that the clinical  
problem of missed diagnosis of anomaly of the external  
genitalia is common (approximately two-third of cases).  
In over three-quarter of cases the diagnosis of un-  
descended testes was missed while the diagnosis of hy-  
pospadias was missed in two-third of cases. Thus, sug-  
gesting that among the anomalies of the external genita-  
lia, undescended testes was the dominant clinical condi-  
tion whose diagnosis was missed. This observation is  
not surprising as it is16i-n19 agreement with the report of  
Conclusion  
In conclusion, the routine newborn examination as cur-  
rently practiced in the two hospitals was weak in detect-  
ing anomalies of the external genitalia. Poor documen-  
tation of the findings on physical examination of the  
external genitalia is a common phenomenon in the set-  
ting where we practice, irrespective of whether the  
healthcare institution is tertiary or secondary.  
several other studies.  
However, there was no Nige-  
rian study reporting on the subject for comparison. The  
high rate of missed diagnosis observed in this series  
suggests that inadequate attention is being paid to  
Conflict of Interest: None  
Funding: None  
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