Documentation question

[RaeT,RN]

Ok, so I have a question:

Let's say you're the nurse in a delivery, 16 YO G1P0, and the baby is OP. You observe the MD apply the bell kiwi vaccuum and pull once (pops off), twice (pops off), and three times (pops off). He then says to you, "Give me the flat kiwi. This vaccuum stinks." :stone So you then observe him to make two more pulls with the flat vaccuum, both of which pop off. He then asks you to apply fundal pressure, and when you (being a prudent nurse) do not do it, he puts his own hands up there and pulls foreward. This poor kid has the worst cephalohematoma - like the size of a lemon.

In the physician delivery record in the chart he documents that it was an uneventful lady partsl delivery, with 3 vaccuum pulls.

In your delivery record, what do you document? Do you document the three because he did, or do you document the 5 that you saw??????

[SmilingBluEyes]

Actually we have a place for vacuum delivery-specific documentation on our delivery room record form. We do document how much mmHg pressure was used PLUS how many times the vacuum was applied. There is a space for this specifically on the form. Our delivery room record is really quite specific , noting many different specific facts pertaining to each delivery. You should note the mmHg pressure used and how many applications you noted for each VAVD on the delivery record/nurses' note or form (depending on what is used in your institution).

As far as the fundal pressure issue, that is for an occurence/incident report. I would document this on that report, for the risk management department, as well as my manager/house supervisor's review. Our incident reporting system allows multiple notifications and automatically goes to Risk Management for review.

Be VERY careful what is charted IN THE PATIENT CHART itself for liability purposes----if you observed true fundal pressure used by the physician after your refusal, document every detail on the incident report and be sure to make sure your charge nurse and manager are aware, or CC'd the report for their notification. Also, be sure you discuss this face-to-face with the manager, as well, for a heads-up. This is exactly how I would handle it.

If you are in doubt, you really should discuss this situation with the nurse manager in detail, before proceeding further. Just be sure whatever notes you make in the chart are VERY objective and factual, as well as clear. And be sure what goes in the chart versus an incident report.

Repeated problems with physicians of certain nature are discussed at our Perinatal Committee Meetings and worked out, where I work. A paper trail is needed in order for action to be taken on such dangerous interventions. I have actually seen certain priveledges suspended , in exceptional cases, in the past. But it took a careful documentation and reporting system to make it happen.

Good luck!

[RaeT,RN]

I'm sorry, Deb, I guess I should have been more specific. We use the QS computer documentation system, and in QS is the nurses' delivery record. The physicians have a paper delivery record, with boxes to check for delivery method, Apgars, weight, etc, that stays in the pt's paper chart. We print out our copy of the delivery record, and it goes under the same tab in the pt's chart as the physician's record. I am leaning towards documenting what I actually saw (ie. 5 pulls), but when the physician documents 3 pulls on his record, I am curious what happens if I document 5? How does that discrepancy look, especially in court?

Edited to say:

You probably remember the post I made a few months ago about fundal pressure. I know about the risk management form. The doctor I mention in this post is actually a different doctor than the one I spoke of before. Coincidently, I have not had another delivery with the "cowboy" yet, but I have heard that he is still doing the fundal pressure in the majority of his deliveries. Believe me, I tell them every time I hear about it that it needs to be documented on that QAR. Whether it actually gets done or not, who knows . . .

[SmilingBluEyes]

Yes, document what you SAW, not what he put in his progress note. It won't look good, no, but if you do not document what you truly saw, and you were asked UNDER OATH what you saw, you realize your integrity could come into question in a court of law---e.g. saying you saw 5 but only documented 3.

Here's a scenario for you: The Lawyer asking you in your pre-trial deposition: "Well what WAS it---- 3 or 5? How do we know you are telling the truth NOW?" Yep I have personally given a sworn deposition---- (not sued or in a trial, but the deposition alone made me sweat)---- and they Do get VERY specific, questioning you and what you charted and why. I learned the story better match the chart. And your memory is not perfect, so all the more important your charting be objective and accurate.

(Lawyers) They are aware nurses' and physicians' notes MAY look different and yep, that will be a sticking point. But YOU don't want to lie.

I have documented different things in my nurses notes from physicians before. Do I like to? No, but I have to chart objectively what I witnessed or did personally.

This is where the incident report comes in. You can use it (separate from the patient chart) to explain the specifics of what you saw in detail, covering yourself legally and from a risk management standpoint. The physician can chart what he/she chooses, let him/her defend it later on, if it comes to that in a court of law. You know what you saw and you can't abdicate your responsibility to report it as you witnessed it.

Keep up the great work.

[SmilingBluEyes]

Here's a good book for you:

http://www.proedcenter.com/cart/courses.php?view=course_material&book_detail_id=26&quantity=1 (you get continuing ed credits if you order this book and do the homestudy with it)

OR you can get the book much cheaper here:

http://search.barnesandnoble.com/booksearch/isbnInquiry.asp?userid=In0Ri5JAu6&isbn=0323004318&TXT=Y&itm=9

Really, it does not matter whether you use automated charting or paper charting---- or a combination of the two........you still need to be sure the account is accurate and objective and something you would SWEAR to in a depostion or court of law.

Also attend, if possible, some good Legal Nursing Seminars; they will really open your eyes some. Some of the things I have learned through the years have really given me pause to consider the liability of what I do everyday, and how litigious things are really, in nursing, particularly in OB. It's no cakewalk, hmmm?

[RaeT,RN]

Thanks, Deb. I'll definately check those out!

[SmilingBluEyes]

Good luck. Dont' think for a minute, I did not struggle as you are now. I have learned a lot of lessons the HARD WAY. If I can save anyone from having to make the mistakes I have, I am glad to do it.

You seem much more a quicker study and smarter learner. You are very conscientious. I hope I have helped you some. You are doing a terrific job, Rae!

[Jolie, BSN]

I agree that you must document what you observed, regardless of whether or not it agrees with the doctor's notes. If there is a discrepancy, so be it. I suspect most juries would realize that the nurse has nothing to gain (or lose) from objectively documenting his/her observations. The same can not be said for the physician, who may be trying to cover up inappropriate interventions. I suggest that you complete your notes without reading what the physician has written, then there is no question as to what you should document.

I became aware of inaccurate documentation of my delivery the next day on post-partum. My daughter had an occult prolapsed cord, which necessitated a quick delivery. The doctor injected local anesthesia, but couldn't wait for it to take effect before cutting an episiotomy. I felt the first snip, and heard the second, as he made 2 cuts to "open things up" so that he could quickly pull her out. I don't question the necessity of that, and am grateful that he got her out so quickly. But neither he nor the nurse documented the episiotomy as it actually occured. They both noted "midline episiotomy". It was both a midline and mediolateral.

The next day, I had such pain that I asked my post-partum nurse to check it for me, as I wondered if I may have had a clot. I told her that I had 2 cuts, which she doubted, since it was not documented that way. Much to her surprise, there were 2 large incisions.

I know that mediolateral episiotomies are not commonly used, and it may not have been strictly necessary, but I would never have questioned it, as my daughter was born healthy, when the outcome certainly could have been different. I'm sure the doctor omitted the documentation in order to aviod explaining the use of a potentially unnecessary procedure. It never made sense to me that the nurse omitted documentation as well.

It certainly didn't do anything to improve my faith in either of them. I also wonder how they would explain the "sudden" appearance of a second cut, which the post-partum nurse documented the next day!

[SmilingBluEyes]

Wow thank you for that post Jolie. A good reminder from the patient's perspective----trust is a big issue. Yours was somewhat compromised in the simple lack of accurate documentation. I am glad you shared this with us.