Charting in Obstetrics

[Jesslan84]

I started on a new ob unit and was told I was documenting time wrong on my EFM. I chart at 2100 what happened from 1930-2100 Is that incorrect?

[klone, MSN, RN]

I'm not sure I'm following you. What exactly are you charting at 2100 that happened between 1930 and 2100? Are you working L&D? Mom/baby?

Whenever possible, you should be charting in "real time" as it happens, particularly in L&D.

[Jesslan84]

Yes I'm working L&D. I'm asking about charting what happened on Electronic fetal monitoring strip. For example: at 2100 I document my base line FHR ,contractions, things like acceleration or deceleration seen during the time frame of 1930-2100. I have worked L&D for over 8 months and was taught to chart that way at my last job. The new facility that I am working at now said that that is wrong that I should chart what happens from 1930- 2100 on the strip at 1930. I am really confused now because that is opposite of what I was taught and doesn't really follow Nursing charting. Why would you chart something before it happened?

[klone, MSN, RN]

IMO you're both wrong (although I suspect that actually you're misunderstanding what they're telling you). You should chart what's happening on the strip at 1930, at 1930. You should look at your facility's policy on frequency of charting, but where I've worked, it's always been expected to chart every 30 minutes during active labor, every 15 minutes during second stage, and every 5 immediate post-CLE placement. So I would chart what the strip is doing at 1930, 2000, etc. In addition, if there was anything weird that happened, such as a decel or baseline change, I would chart that at the time, irrespective of when I last charted.

[ashleyisawesome, BSN, RN]

I can't think of a situation where I would only be charting on my strip every 1.5 hours. Even an induction I chart q1h at minimum. When I am charting q1h I am charting for the entire past hour. So if the strip is from 1900-2000, I will chart at 2000 what the baseline, variability, reactivity, etc was from 1900-2000.

Labor patients are charted on q30 mins for low risk, early labor, then q15 mins for high risk or active labor. So if I was charting q30 mins from 1930-2000, my charting for 2000 would include everything I observed from 1930-2000 (baseline, variability, decels, etc). For specific interventions I always chart the exact time it happened. So if I turned the patient on her left side at 1937, I would chart that at 1937. If the doctor came to the bedside at 1942, I chart that at 1942. If there was a major decel (not just a few small variables or earlies, something like a 3 minute slow return to baseline) I will also chart the exact time and what I did and the exact time I did it.

[Skips, MSN, RN]

I chart in 30 minute intervals. However, for big decels and rescuscitation measures, I chart exactly when I did it. Just like the PP says.