I posted a question a while ago asking for documentation tips for new OB nurses. I've learned a few things that I thought I'd pass on:
When someone comes in for triage (we serve as ER for all pregnant women), on the nursing note I usually say something like:
"Pt reports contractions started at 8 pm; occurring q 15 minutes. Pt reports no fluid leak or blood per lady parts or odor. Pt reports positive fetal movement. "
If the patient's BP is up I will write something like: "Patient denies headache, RUQ pain, and blurry vision. Urine dip reveals ________."
When a patient is leaving I have been taught to write: "Patient is discharged to home. Patient verbalizes understanding of discharge instructions; written instructions given."
I think these things are so automatic for experienced nurses that they don't even thing about them, but learning which phrases to use in our documentation is very useful for us newbies.
I don't know where to start here. There is a need, in this day and age, to not have practice/care influenced totally with the fear of being sued. It is no way to live or care for a patient, but it is an animal with which we need to deal with. Unfortunately we live in a place where lawyers know MORE about OB than they need to, and use it against those who care for patients. It isn't necessarily the right thing, but it is happening. Knowing standards of care and your hospital's policy on charting will protect you against claims of negligence. That is what they are there for. You MUST follow your policy on charting, use the nomenclature as stated and not deviate from that..unless you write narrative note. If you do not follow this, what you have charted may not be what you interpreted or did. I find this so many times when I review cases. The nurse has every intention to say the baby was reactive, but does not chart as such because she did not follow their hosptials policy on charting. It doesn't matter how others chart. Looking at others charting doesn't help you if it violates what your facility has dictated as policy. You must also know national standards of care. You are held to those standards also. Not knowing them is not acceptable in a court of law. You policies should reflect them. Remember, they are there to protect you as well as be your guide in care.
SBE mentioned NICHD nomenclature. It is coming. This will alleiviate all of the ambiguous charting and clever little ways we document decels and the like. Again, it only works if you USE it and use it properly.
Education is key here. READ READ READ READ. Go to classes, seminars. It is the thing to do.
Wow! Whatever happened to a gracious "Thank you for your input!"
:yeahthat:
SmilingBluEyes obviously takes her charting seriously as well we all should. I felt she provided the best response to the initial question with her first post in this thread, which BTW did not sound pompous or arrogant to me. I felt she provided information in a sincere manner.
I don't understand why you responded to her this way amber1142. You did ask for advice, specifically in regards to L&D.
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.
Holy cow, Amber! You introduced an important topic for discussion. So why get riled when someone wants to discuss it? It isn't necessary to call a fellow poster rude or pompous or patronizing just because they don't agree with you. Deb was very gracious in her attempts to clarify her posts and in finally withdrawing when that proved problematic. She didn't make accusations about your behavior as you did hers. She did challenge some of your statements but that's supposed to be okay in this forum. Dissent, in and of itself, is not an attack.
Deb (SmilinBluEyes) not only knows her stuff, she is willing to share her knowledge in a down-to-earth and understandable manner. She generally provides rationales for what she says and often posts links that examine the topic at hand. I saw nothing in her posts that should have given offense and, as a new birthing center nurse, I am grateful for the knowledge she presented. I'm going to print out her tips and keep them with my work notebook for future reference.
I've been a nurse for 11 years and an EMT for 17 years and let me tell you, Deb is right on target. For all their high-minded rhetoric, courts don't focus on morality. They focus on assigning liability and making someone pay. You can be the best, most moral practioner in the world, but if you choose the wrong phraseology in your charting or if you forget to mention something, you could be made to look incompetent and uncaring.
Newbies do not need to be afraid so much as they need to be aware. Then they can do what it takes to become wise in the ways of charting. It's a shame that healthcare professionals need to learn to chart defensively, but it's a reality that you ignore at your peril.
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.
voting on a close of this thread. perhaps the op can try this discussion after a cooldown period. For the record, I thought smilingblueeyes was trying to be very helpful. A simple thanks, but i'd like to try it my way would have sufficed, or the good old ignore button if you really didn't like what was posted. I can see that you are fairly new here at allnurses. Welcome, and enjoy the fourms, but try to understand that we are a diverse group of people with differing opinions. A lot of these nurses have worked all over the country in many different capacities, and their knowledge and experience is welcomed and appreciated. Their advice is something worth thinking about.
voting on a close of this thread. perhaps the op can try this discussion after a cooldown period. For the record, I thought smilingblueeyes was trying to be very helpful. A simple thanks, but i'd like to try it my way would have sufficed, or the good old ignore button if you really didn't like what was posted. I can see that you are fairly new here at allnurses. Welcome, and enjoy the fourms, but try to understand that we are a diverse group of people with differing opinions. A lot of these nurses have worked all over the country in many different capacities, and their knowledge and experience is welcomed and appreciated. Their advice is something worth thinking about.
My initial response to SBE was a simple disagreement. Go back and read it. (Edit: In fact, read my first two posts in response to her. I was not rude in any way. She thought I was accusing other people of being not being morally defensible. She was the one who became defensive and accused ME of being rude.) She took it further because she didn't like my response. We are allowed to disagree with her, aren't we? (though when we do that we're accuse of being "rude" and "inexperienced" and told how "we'll see what it's really like" That sure sounds like being patronizing to me)
Apparently when you're a moderator you're allowed to lecture and accuse people of "tilting at windmills" any time you want.
The original question was about tips on charting, which a few people gave. OF COURSE one has to check professional standards and institutional policies. What kind of dummy wouldn't know that? I suppose some people think they need to point out the obvious because they think it makes them look really smart.
BTW, she couldn't resist a private message to me telling me to stop addressing her. She obviously can't stand dissent of any kind.
I've been on email lists and discussion boards for many years, and I know how they work. I understand that boards have "favorites" who are allowed to get away with **** with impunity. I have no interest in listening to lectures and walking on eggshells when I disagree with someone.
My initial response to SBE was a simple disagreement. Go back and read it. (Edit: In fact, read my first two posts in response to her. I was not rude in any way. She thought I was accusing other people of being not being morally defensible. She was the one who became defensive and accused ME of being rude.) She took it further because she didn't like my response. We are allowed to disagree with her, aren't we? (though when we do that we're accuse of being "rude" and "inexperienced" and told how "we'll see what it's really like" That sure sounds like being patronizing to me)
Apparently when you're a moderator you're allowed to lecture and accuse people of "tilting at windmills" any time you want.
The original question was about tips on charting, which a few people gave. OF COURSE one has to check professional standards and institutional policies. What kind of dummy wouldn't know that? I suppose some people think they need to point out the obvious because they think it makes them look really smart.
BTW, she couldn't resist a private message to me telling me to stop addressing her. She obviously can't stand dissent of any kind.
I've been on email lists and discussion boards for many years, and I know how they work. I understand that boards have "favorites" who are allowed to get away with **** with impunity. I have no interest in listening to lectures and walking on eggshells when I disagree with someone.
truern
2,016 Posts
Wow!! In over 20,000 posts I don't believe I've ever seen BluEyes be pompous, rude, or any of the things she's been accused of.
Dang.