balancing charting and pt care

Specialties Ob/Gyn

Published

i am a new rn to l&d/antepartum/pp after 1 year in med/surg. i am loving things so far, off orientation x1 month now and doing well for the most part.

what i really struggle with is how to keep up with the charting demands (ex: fht's every 5-15min depending on pt risk factors and stage of labor). i am really struggling b/c i want to be there for the pt as an additional support, especially when they get active, but of course this is when charting demands (per protocols) get more intense too.

so far, unless my patient has a great support person, i have not been able to stay up on my charting...i am usually fine during 1st stage but really fall behind during pushing, etc, when i am guiding and assisting with pushing and doing what i love to do and really, i feel, helping the pt to focus and bring that baby down... i know this is something that will get better with time, but i find i always stay over about 30 minutes to an hour catching up on charting especially if my patient delivers near the end of shift (which they always seem to!)

any advice, tips, or feedback appreciated! thx.

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Specializes in Community, OB, Nursery.

Do you have computer or paper charting?

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thanks for the reply. we have computer charting (electronic fetal monitoring) but our monitors also print out a paper strip (which is handy to quickly jot a note of an event and then transfer to computer when time allows).

our paper records are archived somehow and then our labor is charted electronically and printed and archived to pt's medical record #.

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Specializes in Community, OB, Nursery.

I agree - babies love to hang out until shift change to decide to make their grand entrance. ;) If that's the case, I don't see as how there's much you can do about it regarding charting. Your patient is your priority while she's pushing. If you have to stay over your shift to finish up, especially now while you're still learning the ropes, it shouldn't be a problem. (Cuts into your sleep/relax time, but that's another story....)

What some L/D nurses do where I am is finish a few minutes' worth here and there while they're turning a patient over to mother/baby, if your unit an LDR and doesn't keep the pt after they deliver. But we have paper charting (in transition to computer stuff) still, so I'm sure that makes a difference in when and where we can chart.

In time you will develop your own abbreviations for those times you're scribbling on a paper towel to transfer later. That helps too. Every second helps. I'm sure there are other posters who've been at it longer than I have that have other pointers. And if I think of anything else, I'll post again. :)

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Specializes in L&D.

Ah, the nurse's age old problem: finding the time to both do the nursing care and to chart the nursing care. You'll get better with practice. You'll develop your own formula for expressing yourself. Certain phrases, etc that you use.

My hospital still uses paper charting and keeping people up to date is a problem. One of the mistakes new nurses make is they think they have to be at the desk to chart. At first, that may be OK since they want to discuss the strip and what they're charting with their preceptor before putting it on paper, but to stay up to date, they have to learn to start writing in the patient's room. I can hold a patient's hand with one hand while writing with the other and verbalizing my coaching mantra (That's the way, good job, take another breath, perfect, that's it, you're at the peak, it's on the way down, good job, keep breathing, almost gone...) all at the same time, but I've had lots of practice.

Advice I give new nurses, don't chart the same thing more often than you have to. Our paper charts have a separate place to chart medicine, but a lot of new nurses chart it in their narrative as well as in the special place for meds. Same thing with MD notification. We have a special place to chart the times we notified the doctor, the time, the nurse's concern, the MD's response. So it only needs to be noted in that one place. You may not have these exact things, but I'll bet there are some things that you chart in two places when one would do. The more places you chart the same informationl, the greater the chance you'll make a mistake in transcription and say something was done at 1301 in one place and 1307 in another. Lawyers love to find this kind of thing. "So, Nurse Ratchett, just when did you do that procedure? If you did it at 1301, why did you chart in this other place that you did it at 1307? Just which are we to believe? Are you sure you didn't do it twice? Did you do it at all? How much of your other charting can we believe is accurate?"

Don't be so wordy. Some nurses will chart that such and such a thing was done per order Dr So &So. If there's a written order for it, you don't have to write that phrase. Learn to use your hospital's accepted abbreviations, just don't make up your own. You mentioned charting fetal hearts q5min. The standard says FHT should be assesssed q5m during second stage, not documented. If you have continuous EFM, and are in the room and paying attention to the monitor, you're assessing it. You can document q15min while saying you're in the room and continously assessing the tracing. If you're doing intermittent ascultation, you'll document each time you take it.

If you get behind, start documenting where you are and do the rest as late entries (which they will be anyway). Document it when you do it. It's easier to write a BP when it's taken than to page back through hours of strip. Your notes will also be more accurate. When you're trying to get home to sleep so you can be back in time for your next shift, and trying to recreate the last 2 or 3 hours of someone's labor, you can forget things. You will develop a rhythm with your coaching and documentation and you will get better at staying up to date. But nothing is likely to get you out on time with a change of shift delivery. That's just one of the facts of life in L&D.

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I write on the strip or on the paper towel I carry in my pocket ;). . . and then reconstruct the whole dang thing afterwards.

It is hard to do patient care and the charting - I focus on the patient care and jot down times of events.

The paper towel usually has the time of birth, the first vitals signs, the time of placenta delivery. Sometimes the doc takes the paper towel to make his charting notes.

steph

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I am from the "old school". I graduated 40 years ago and my philosophy is patient care is always first That,s why we do what we do...for the patient. I always have a small note book with me to write notes and time on. It makes life so much easier:balloons:

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Specializes in OB, Telephone Triage, Chart Review/Code.

When I trained in L&D as a Grad nurse, we sat at the pt's bedside and documented. We didn't have centralized monitoring. At that time also, we were paper charting and I would write everything on the strip...for instance, 02, cus it only took a second to do that after I placed the mask, especially when pushing..."P" for pushing.

It was hard when charting changed to computer. I still would make small notes on the strip because we were supposed to log out everytime we left the room and it would take a few minutes to log back in to chart an intervention. I did some Travel Nursing and it was a pain to learn each hospitals computer system!!!!

You could ask your collegues what "tricks" they do and from the group of them, I am sure you will pick out things that work for you. Hang in there. It's always been my philosophy that the patient and family come first.

I once had a manager call me to her office to tell me that I spent too much time with my patient! The other nurses were noticing that I wasn't at the desk watching the monitors with them. Hmmmm.

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When I trained in L&D as a Grad nurse, we sat at the pt's bedside and documented. We didn't have centralized monitoring. At that time also, we were paper charting and I would write everything on the strip...for instance, 02, cus it only took a second to do that after I placed the mask, especially when pushing..."P" for pushing.

It was hard when charting changed to computer. I still would make small notes on the strip because we were supposed to log out everytime we left the room and it would take a few minutes to log back in to chart an intervention. I did some Travel Nursing and it was a pain to learn each hospitals computer system!!!!

You could ask your collegues what "tricks" they do and from the group of them, I am sure you will pick out things that work for you. Hang in there. It's always been my philosophy that the patient and family come first.

I once had a manager call me to her office to tell me that I spent too much time with my patient! The other nurses were noticing that I wasn't at the desk watching the monitors with them. Hmmmm.

We don't have central monitoring either. So, jotting things on the strip is important. And we have to initial it that we've assessed it per protocol. I chart in the room as well.

When things start to happen, I chart on the strip and grab a paper towel.

I can't imagine having to use a computer. I know I would hate it.

steph

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Specializes in Labor & Delivery.

This is kinda funny to read seeing that I am a new nurse also (june 08 will make 2yrs as a nurse AND L&D nurse), this topic and responses made me smile and say "gee, I was JUST LIKE THAT!!!" :) It's very reassuring to read that everyone more or less has the same "problem" as an L&D nurse. SNWFLKNURSE, trust me when I say, it gets easier. You stated that you just came off of orientation, 1 month I believe. I oriented at my hospital (a high risk, high volume, high acuity hospital - 35-60 deliveries a day!) for a total of 19wks (usually you only get 12-14wks) because I wanted to be SURE I was ready to fly solo handling 2pts adequately. It took me 6 months off orientation to feel like I had a handle on this L&D nursing thing. I work nights so it became a routine for the day shift nurses to playfully heckle me and say "Carrie, you pulling a double again?" I just didn't feel right charting q5 minutes while pushing with the pt. It seemed to me (as was stated here by someone) that I wasn't being there for my patient when she needed me most - especially during a primip delivery. SO, I stopped doing it - the charting at the bedside thing while pushing. What I also found was that because I was so busy trying to chart and not enough time helping mom push "properly" the time it took for patient to deliver extended. By paying attention to mom during pushing, applying perineal pressure where and when she needed it to allow for her focus, cheering her on (sometimes I think I get more excited than they do when she delivers- I get really animated - laugh, tear up (especially when dads cry - gets me EVERYTIME), etc) when she feels defeated, etc., holding one leg so as to show the family member holding the other leg the proper way to do it, etc. I found that I could get a delivery (primip or not) within an hour from start of pushing. I'm a firm believer in the laboring down thing (allowing the pt to labor down to +1 or +2 station before starting to push) and so I advocate for that ALL THE TIME when the docs want me to start pushing at 0 station. The moms get so pooped out when they start at 0 station and have little to no energy by the time they get to +2 or +3. To this date of my practice, I have not had to push longer that 1.5hrs with a pt. As for the charting, when I was at my hospital where I trained, we did paper charting and I always charted AFTER the delivery. You kinda end up writing the same thing over and over again q5 mins during pushing, so I just created a pattern that I stuck with "date/time- Pt pushing effectively with ctx. FHTs in 120s AVG variability, MD at bedside." and repeated that statement q5mins unless there was a variable, then I'd throw in "mild variable/deep variable noted with pushing, FHTs return to 120s after ctx and pushing" (tailoring the words as needed for the situation).... I'm doing my first travel nursing assignment right now and this hospital uses computer charting. I LOVE IT, LOVE IT , LOVE IT!! They are using the QS system and basically if nothing has changed from 5mins to 5mins, you basically have the option of copying the previous column to the new 5min column instead of retyping all that stuff. You also can just click on the strip and indicate "RN at bedside, Rn reviewed strip" which makes charting during pushing a sinch! Anyways, don't be too hard on yourself, you will be a RN for the rest of your life.... you have an eternity to "standardize" your own specific way of charting that will say everything without saying EVERYTHING. :) In the mean time, just know that in L&D you almost NEVER get out of your shift at 7am or 7pm.... hopefully it will be 7:15 instead of 8... I can remember getting stuck with a 5:30am admission who went from 2cms to complete to delivered before I could get her chart together properly and then staying till 9:30am charting my admission, plan of care and delivery after handing her off to day shift for the last 3 recovery checks! Oh did I mention that she PRECIPTED - so the charge nurse stayed with me and did the incident report while I did my charting! :) I JUST LOOOOOOVE MY JOB!!! What other profession can be this exciting??? :w00t: :cheers:

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