Describing Decels

[Valerie RN, BSN]

I took a FM class about 6 months ago and they stated that describing decels ex) - fht's with contraction to 100 lasting approx. 50 seconds before returning to BL - could potentially hang yourself in court if, for example, it was a 60 second decel instead of a 50 second decel...they said they try to make you look like you have no credibility. I was just wondering what others do in their charting. My hospital uses Tracevue to chart. We have the option to just put "present" under the decels, but I don't feel comfortable just putting that. I do describe my decels and worry that it could one day bite me in the butt. Does anyone happen to know what looks better in court?

[GilaRRT]

Absolutely, print out the findings, then chart exactly what you saw. If the fetal heart rate decreased to 50 for 10 seconds then went back to 130, chart it as such. If you go to court, the other side will find a way to make you look like you have no credibility regardless of how well you chart.

I commented a while back about witnessing a person get hit by a vehicle literally in front of me. It was pretty intense and I was basically holding the airway open and doing an assessment while waiting for EMS. When the lawyers got ahold of me, I was asked crazy question like if I remembered the vehicle having it's headlights on. When I replied with the truth that I did not know, I was torn to pieces and I was not even the one on trial, I was just a simple witness...

[CarrieRNC]

Does your floor follow the NICHD guidelines? There are only four types of deceleration patterns....variable decel, prolonged decel, early decel and late decel. This is the safest way to chart. I agree, and we all tend to describe decels but what we really should be doing is stating what they are according to the NICHD nomenclature and then stating your interventions.

[Valerie RN, BSN]

Thanks for your response. To be totally honest when I was on orientation we were told about variable decels, early, lates, etc. but almost everyone describes them as I did above or says "present" in the appropriate box. However, it can be very monotonous to chart on every single decel (for example, head compression with every contraction with a 9 cm patient). If there is a variable I usually just chart "variable decel noted" and have even started charting "decel with contraction noted" on early decelerations. I just want to know from a legal standing what is best because I know that you can get yourself in trouble for over charting as well.

[CarrieRNC]

Look up the NICHD guidelines, this is what EVERY OB nurse/MD/resident/CNM etc should be charting by and it is what AHWONN is supporting. For you, if you follow these guidelines you WILL be practicing "safe charting" and you will always have the backing of AWONN if you follow the appropriate interventions. I work in a level 1 hospital where we do about 4500 deliveries/yr. These are our standards and if you are charting on the electronic record then it should be built into your system(depending on what system you use).

[CarrieRNC]

This is a great article about the NICHD nomenclature.

A Review of NICHD Standardized Nomenclature for Cardiotocography: The Importance of Speaking a Common Language When Describing Electronic Fetal Monitoring

[klone, MSN, RN]

Our charting allows for describing the decel. You identify what type of decel it is (early, late, variable), then in another section, you describe the nadir (and it allows you to put in a range) and time until return to baseline (again, allowing for a range).