Charting- again

DusktilDawn · Aug 20, 2005

There are so many different charting formats and each facility seems to have their very own. :uhoh3:

As a student nurse, when I had to research my patients for clinicals, I would also read the area for nurses' notes in order to have an idea about their charting format and how other nurses wrote their notes, it helped inform me on what needed to be in my notes. One facility had their own list of approved abbreviations that I got a hold of courtesy of a friendly medical transcriptionist (also ward clerks can be a good source for this). A nursing instructor imparted this advice: "Chart as if your notes were going to be seen in a court of law" :uhoh21: and "If it's not charted, it's not considered to have been done"

Minou · Aug 21, 2005

What I found useful when I started was to read other nurses' charting to get ideas of what to write ( and sometimes what not to write ). Remember to be accurate, to the point and chronological . re-read your charting and if you're not sure, have somebody else read it and say if they have a clear picture of what you are saying. always remember that a big big reason to chart is for possible litigation in the future. eventually you will develop your own style and for the most part you will chart the same thing over and over again except for the abnormal stuff ( who has time to be creative with every pt, every day ? )

Good Luck,

Minou

SmilingBluEyes · Aug 22, 2005

I have a few suggestions:

Make sure you know your organizations policy and procedures like the back of your hand.

Be a member of AWHONN. (you are held to their standard as an L/D nurse, if you practice in the USA).

Know about ACOG standards/charting.

Take LOTS of classes/attend conferences on L/D issues, fetal heart monitoring, etc. Knowledge is real power. The best nurses (whom I try to emulate) have been to TONS of these and they KNOW their stuff. Classes like those of Michelle Murray and Judith Poole and others are really good to keep you abreast on the issues affecting our practices and charting. Check:

http://www.proedcenter.com

for classes that may pertain to you or you can attend. If there is a nurse-lawyer offering classes/conferences on legal issues, ATTEND IT! It really opens my eyes as to how "open" I have left myself in the past! They are a wealth of information.

Become familiar w/NICHD terminology if you are not already----it's a standard nomenclature system for OB charting (medicine and nursing) and it's coming to a unit near you. You need to know the terminology and exactly how to use it for legally-defensible charting. (e.g. KNOW the difference between "fetal distress" and "fetal intolerance")

Be familiar with occurence/variance reporting systems in place in your organization. Know well what you should report via this system, versus what goes in the chart. This is a real risk management issue, and a CYA thing we all should employ MORE. If you are unfamiliar w/what a reportable situation might be, ask your manager or risk management dept about it.

It's a lot more than looking at others' notes and learning from them. You need to know how to chart in a legally-defensible manner. That comes with understanding key risk issues in OB and charting to prevent yourself from being caught unaware or looking like you did not do all the things you should for a given situation. The old adage "if we did not chart it, it did not happen" still holds today---probably more than ever. But you really need to keep up on professional standards. That comes with being a member of your professional organization to whose standards you are held----and to keeping current on issues pertaining to obstetric nursing.

Good luck!!!!

Good charting follows procedure and protocol.

amber1142 · Aug 22, 2005

I have a few suggestions:
It's a lot more than looking at others' notes and learning from them. You need to know how to chart in a legally-defensible manner.

Believe it or not, I know this. You may not remember what it's like to be starting out, but when people are learning how to chart they start with small steps.

As far as "legally defensible", I like my idea better. I practice morally defensible nursing; I provide good care, and I will document the care that I give. I am not afraid.

SmilingBluEyes · Aug 22, 2005

Well I am sorry, but legal defensibility is what you will find them challenging you on, in court. Not your "morality". Heck, that does not even come into play in the courtroom.......

Trust me on this. I have already been called to give a few depositions/statements to lawyers (never in court myself---nor sued, yet, thank good ness) and THEY WILL RIP YOUR CHARTING A NEW 'one" even in informal depositions. I was made to feel I was a shoddy nurse who did not know her "stuff" once. It was very humbling and yes, I dare say, scary.

You would be amazed with what they pull apart.....so, yes, I stand by my "legal defensibility" statements. If you choose to be unafraid, so much the better for you----until you experience what others have, you have the luxury to do that. And people WILL sue you, even if your practices were sound and "moral". They will sue you (or the dr) anyhow.........even if everything you did was textbook perfect.

If they sue the dr, guess who is going to court with him or her???? You are, if you were involved in that case. Even if you did everything perfectly.

I have coworkers who taught me a thing or two about what it's like in court, being sued---or being w/a dr who has been sued, and having to give HOURS of sworn statements, defending their very practices, minute by minute. It's not pretty, and yes, I am "afraid", or should I say---- very wary. The experiences they went through were rigorous and life-altering. Some quit OB altogether. Others were divorced in the 2 or more years it took to see the whole process through. It tears apart your whole life in some cases.

And their practices (the dr and nurses) were absolutely water-tight, yet they were torn apart time and again in court. So yea, I guess, I am guilty of seeking legally-defensible means of doing my job, for I feel justifiable reasons.

To presume lack of morality on the parts of others who are legally-savvy is unfair and unwarranted on your part.

And just so you know, the comment about emulating other charting styles was addressed to another poster who suggested it in another post.

Now, I am sorry you feel my advice was not helpful. You don't have to listen to me at all---that is your right. To each their own, no has to take advice-----but you asked for advice in this very thread.

See, I DO remember what it's like to start out---how scary---and how really unaware I was of the issues around me---and how easily I could get into hot water then. Ignorance was bliss on my part---when I look back, I consider myself lucky I did not get into trouble then for things I just did not know. Remember, the old saying, "you don't know what you don't know" and the truth behind it. You may not know to be legally-savvy, and ugliness of court cases/trials----- but you will come to know all about it, after time, and experience, believe me.

Good luck in the future.

amber1142 · Aug 22, 2005

Well I am sorry, but legal defensibility is what you will find them challenging you on, in court. Not your "morality". Heck, that does not even come into play in the courtroom.......
Trust me on this. I have already been called to give a few depositions/statements to lawyers (never in court myself---nor sued, yet, thank good ness) and THEY WILL RIP YOUR CHARTING A NEW 'one" even in informal depositions. I was made to feel I was a shoddy nurse who did not know her "stuff" once. It was very humbling and yes, I dare say, scary.
You would be amazed with what they pull apart.....so, yes, I stand by my "legal defensibility" statements. If you choose to be unafraid, so much the better for you----until you experience what others have, you have the luxury to do that. And people WILL sue you, even if your practices were sound and "moral". They will sue you (or the dr) anyhow.........even if everything you did was textbook perfect.
If they sue the dr, guess who is going to court with him or her???? You are, if you were involved in that case. Even if you did everything perfectly.
I have coworkers who taught me a thing or two about what it's like in court, being sued---or being w/a dr who has been sued, and having to give HOURS of sworn statements, defending their very practices, minute by minute. It's not pretty, and yes, I am "afraid", or should I say---- very wary. The experiences they went through were rigorous and life-altering. Some quit OB altogether. Others were divorced in the 2 or more years it took to see the whole process through. It tears apart your whole life in some cases.
And their practices (the dr and nurses) were absolutely water-tight, yet they were torn apart time and again in court. So yea, I guess, I am guilty of seeking legally-defensible means of doing my job, for I feel justifiable reasons.
To presume lack of morality on the parts of others who are legally-savvy is unfair and unwarranted on your part.
And just so you know, the comment about emulating other charting styles was addressed to another poster who suggested it in another post.
Now, I am sorry you feel my advice was not helpful. You don't have to listen to me at all---that is your right. To each their own, no has to take advice-----but you asked for advice in this very thread.
See, I DO remember what it's like to start out---how scary---and how really unaware I was of the issues around me---and how easily I could get into hot water then. Ignorance was bliss on my part---when I look back, I consider myself lucky I did not get into trouble then for things I just did not know. Remember, the old saying, "you don't know what you don't know" and the truth behind it. You may not know to be legally-savvy, and ugliness of court cases/trials----- but you will come to know all about it, after time, and experience, believe me.

I don't assume a "lack of morality" on anyone's part, but I refuse to live in fear (and it's not because I'm new; it's because it's what I believe). (Ever wonder why the csection rate in this country is 25%? why people think hospitals are safe? why EFM is used routinely when there is absolutely no evidence that it affects outcomes? What if people took a stand? What if people said, "I will not be a part of this?). Feel free to practice nursing any way you want; I will not be afraid and I will not contribute to the culture of fear and litigation that led away from evidence-based practice in the first place.

SmilingBluEyes · Aug 22, 2005

I am sorry I have been unclear, but, I did not say "live in fear" did I?

And please remember; you were the one who brought the issue of morality into a what really is a very good, legal nursing question. The funny thing about "morality" is, your morals and beliefs are not necessarily those that others espouse---- your colleagues, the doctors/midwives, the court systems/juries, and most especially, your patients, probably will not always share all your moral values.

Even courts of law are hesitant to legislate "morality"----but they DO know their way around obstetric legal issues, and to say you refuse to "live in fear", really unscores the lack of experience on your part. No one asks you "live in fear". We do advise you become very legally-educated. You will be judged among your PEERS in nursing, remember, so again, morality becomes a rather cloudy issue, here.

Also I ask you please remember the original intent of the thread. It was not concerning evidence-based practices and their virtues. You do not "take a stand" through your charting practices. You do this by educating yourself, staying abreast of current issues in our speciality (why I recommend being a member of AWHONN), being politically-active and advocating for your patients. Or you practice in a setting that more closely matches your beliefs and values.

You don't have to lecture me about the value of evidence-based practices in nursing. I hear you and I agree with you 100%.

Your thread, as I recall, was a request on how to chart ,in so many words. Others gave you their best advice (based on years of experience). Legal issues can and will come into play, in your charting and in OB, no matter your values and morals. Ask your risk managers if they want you to chart based on your moral compass......they don't.

But I do very sincerely respect what you hold dear....so hold onto those moral values you have-----they will make you one excellent nurse. But remember, the courts have tried and convicted (and huge payouts ensued) for excellent nurses , doctors and midwives and it will continue in the future. There is nothing on earth wrong with being the patient advocate while being very legally-savvy. When you get more experience, you will be more skilled at this, trust me.

And you will understand better what I am trying to say now.

Take care.

amber1142 · Aug 22, 2005

I am sorry I have been unclear, but, I did not say "live in fear" did I?

My post was the equivalent of asking for tips on starting IVs, and you answered with the equivalent of a lecture on infection control. I am aware of legal issues; I was asking for charting tips.

Even courts of law are hesitant to legislate "morality"----but they DO know their way around obstetric legal issues, and to say you refuse to "live in fear", really unscores the lack of experience on your part.

This is pompous. I'm sorry, but people who believe differently than you do should not be dismissed simply because they are inexperienced. I happen to be 40 years old and on my third career. Different ways of thinking of litigation and risk isn't a matter of experience (ask any midwife).

You do not "take a stand" through your charting practices.

No, you don't. Some people are comfortable playing games like writing "decel occuring late in time" rather than "late decel" while cranking up the pit on a vbac patient. I'll save my fear and concern for where I think it matters.

SmilingBluEyes · Aug 22, 2005

good luck then. I am neither pompous or rude as a rule----if I appear that way, I apologize. I am trying to help, period. I, too, am an older late entry nurse with a couple other careers under my belt. And I speak to you as a nurse with 8 years' ob/gyn nursing experiences, some tragic and scary.

I will say more thing. When you ask for advice on an open board, be prepared to get some you do not agree with or even find offensive. Instead of attacking the other person as "pompous" or anything else, why not try a more reasonable alternative? Ignoring it. You don't have to "tilt at Windmills" to get what you need or express yourself......

Now, I will just withdraw and leave it to others who may have advice more to your liking.

amber1142 · Aug 22, 2005

good luck then. I am neither pompous or rude as a rule----if I appear that way, I apologize. I am trying to help, period.
I will say more thing. When you ask for advice on an open board, be prepared to get some you do not agree with or even find offensive. Instead of attacking the other person as "pompous" or anything else, why not try a more reasonable alternative? Ignoring it. You don't have to "tilt at Windmills" to get what you need or express yourself......
Now, I will just withdraw and leave it to others who may have advice more to your liking.

How about if I agree to work on my style if you agree to work on yours. I'll stop being "rude" if you stop being patronizing; I'll stop tilting at windmills if you stop lecturing.

Jolie, BSN · Aug 22, 2005

How about if I agree to work on my style if you agree to work on yours. I'll stop being "rude" if you stop being patronizing; I'll stop tilting at windmills if you stop lecturing.

Wow! Whatever happened to a gracious "Thank you for your input!"