documentation

kakamegamama · Jul 25, 2008

Lisa--I'm more than a little concerned that you are due to come off orientation in one week and are still struggling with documentation, it appears. This is something you should have been mentored about during the course of your orientation. Documentation is one of the leading issues regarding malpractice in the OB setting. So, my question is---what type of orientation HAVE you had regarding documenting the very things you've asked about?

babyktchr, BSN, RN · Jul 25, 2008

I was thinking that same exact thing. When I am orienting new folks, those things are addressed and you aren't out of orientation until they are satisfactory. I think you should be bringing this up with your preceptor, or CNS. They most certainly should be addressing this issues with you.

shortstuff31117 · Jul 25, 2008

My advice would be to look at other nurses charting. This is what I did, and it really helped me to form my "standard" charting notes. Are you doing written charting, or computer charting? We use computer which makes is somewhat easier. I don't usually write an admission summary, unless its a scheduled c-section, which we do on paper. I'll write something like pt. admitted for scheduled repeat c-section, placed on EFM, IV started, consents signed, POC discussed. etc. etc.

For 2nd stage, I'll write pushing instructions given, pt. verbalizes understanding.

Our delivery summary is a form we fill out in the computer, but I'll write something like, viable baby boy born via NSVD, over intact perineum.

Just look at every chart you can get your hands on, it will help you a lot.

LittleLisaLawrence · Jul 25, 2008

i haven't had anything official regarding documentation although i've looked at my preceptors notes and i've kind of formed my own (see below). i feel like i might be leaving out important info or may not be succinct enough.

here's an example of my admission note:

[color=gray]

___ yr old g__ p__ under care of dr. ____ presents @ ____ weeks ambulatory from home [color=gray](or wheeled up via wheelchair from ed) with report of ruptured membranes [color=gray](or regular uterine contractions). escorted to ldr ___. to br to change clothes and obtain urine sample then to bed. manual test of fetal monitor performed, test lines indicate that the monitor printer is properly functioning. leopold's maneuvers performed to locate fetal back and presenting part. pt encouraged and assisted to move to a r lateral position in bed. efm & toco applied. pt reports active fetal movement--audible on efm. pt denies any leaking of fluid or lady partsl bleeding. pt denies ctx's. pt reports (+) fetal movement today.history in progress.

here's an example of my arom note:

immediately prior to artificial rupture of membranes, fhr baseline ____, moderate variability, spontaneous accelerations to the ____'s and no noted decelerations. upon completion of arom no umbilical cord is palpated, small [color=gray](or scant or moderate or large) amount of clear, watery consistency, normal smelling amniotic fluid. fhr baseline ____, moderate variability, spontaneous accelerations to the ____'s and no noted decelerations. contractions every ____-___ minutes, lasting ___-___ seconds. abd palpates soft between contractions. contractions palpate mild.

here's an example of my 2nd stage note:

rn remains at bedside throughout 2nd stage; assisting patient with pushing; evaluating fetal monitor strip. pushing efforts adequate. patient states pain relief from epidural remains adequate. room set up for delivery. dr ___ [color=gray]and nicu aware that patient is pushing. will notify when needed for delivery.

here's an example of my delivery note:

spontaneous lady partsl delivery of viable [infant's sex] @ [time] over an intact perineum by dr ____. [color=gray]1st degree lady partsl/perineal laceration (or 2nd degree [color=gray]episiotomy)[color=gray] repaired. infant vigorous at birth - - spontaneous cry, pink with bilateral acrocyanosis of hands and feet, placed on pt's chest to begin bonding after fob cut the cord. tactile stimulation & bulb suction of nose and mouth of infant done on pt's chest. apgars 8/9, remains in room with mother. to warmer, footprints done, id bands applied. infant wrapped and given to pt. nursery notified of infants delivery time, apgars, and that the infant is of "average size." nursery nurse on her way to assess infant.

what do you ladies think of my notes?

RNLaborNurse4U · Jul 25, 2008

You're writing way too much, I think. Are you using computerized charting at all, or is this all paper charting? We use computerized charting (QS system), and many things we can just click on the choices for documenting.

As for free-texting notes, we do that when it's not something that can be clicked in the computer. Here are some examples:

"Pt arrived ambulatory to L&D #4 with c/o contractions every 5 minutes since 1700 today. Pt rates them #4/5 on pain scale. Using breathing techniques. Denies SROM or VB. + fetal movement. EFM applied."

"Pt arrived via ambulance with c/o 'feeling like I have to push'. SVE revealed cervix is 1cm/50%/-3. Pt states feeling some cramping today, but denies SROM or VB. + fetal movement. EFM applied. Will notify MD of pt arrival."

"Pt arrived ambulatory for gel induction for suspected macrosomia. Pt denies UC's, SROM or VB. + fetal movement. EFM applied. Gel induction process explained to pt and FOB. Questions answered."

Those are my general guidelines for admission notes. I always do an admission note that contains: how pt arrived (ambulatory, w/c, ambulance), what her complaint is, quantifying her complaint with times/colors (for fluid loss)/quantity (for bleeding), and I ask and document about contractions, fluid leakage, lady partsl bleeding and fetal movement. As well as that I applied EFM.

For AROM/SROM, I don't annotate FHR before and after rupture. It's all seen on the computerized monitor strip.

Seriously, there is little need for my to annotate much more beyond what's already put in our options under the QS system. I really like it!

hoppermom3 · Jul 26, 2008

We do all paper charting. I have cut back on my charting. When I started, I was taught to write an admission note similar to yours, Lisa. After attending a few conferences, I realized that I was doing a lot of double charting. I decided it was a waste of time to mention the pts age, dr, G/P, or gest age when all this info was on either the pt label at the bottom of the chart, or already written by me in the blanks across the top of the chart.

Same goes for narrative charting t/o labor. I faithfully fill out my flowsheet at the proper intervals, but only write in my narrative things that are not on the flowsheet. If I have already charted my SVE on the graph on the chart (with the time performed), I don't also write a note about it.

I have taken some heat about this practice from fellow nurses, who were taught that you should be able to read the narrative only and get a full picture. I feel though, that I am now spending more time at bedside where I belong. I am careful to be thorough, but am much more concise than I used to be.

LittleLisaLawrence · Jul 26, 2008

We have QS, but I find myself double or triple charting sometimes like with medication administration or the pitocin level (whether it was increased, decreased or turned off).

jenrninmi, MSN, RN · Jul 26, 2008

i'm a new l&d nurse (scheduled to get off orientation in 1 week!) and i need help with documentation, specifically nursing narratives. i've looked everywhere for a book specifically for ob charting but to no avail.
what do you ladies usually write for events like...
- the admission note
- arom
- amnioinfusion
- pt education regarding 2nd stage pushing
- delivery summary
*examples of the following would be so helpful*

what computer system are you using? we use ob tracevue where i work and the following are just a click in the system...

arom, amnioinfusion. we have a patient education record that goes in the chart and it is also just check-offs. no narratives. the delivery summary, "nsvd of baby boy, apgars 9 & 9. that's all we need.

good luck!

jenrninmi, MSN, RN · Jul 26, 2008

i haven't had anything official regarding documentation although i've looked at my preceptors notes and i've kind of formed my own (see below). i feel like i might be leaving out important info or may not be succinct enough.
here's an example of my admission note:
___ yr old g__ p__ under care of dr. ____ presents @ ____ weeks ambulatory from home [color=gray](or wheeled up via wheelchair from ed) with report of ruptured membranes [color=gray](or regular uterine contractions). escorted to ldr ___. to br to change clothes and obtain urine sample then to bed. manual test of fetal monitor performed, test lines indicate that the monitor printer is properly functioning. leopold's maneuvers performed to locate fetal back and presenting part. pt encouraged and assisted to move to a r lateral position in bed. efm & toco applied. pt reports active fetal movement--audible on efm. pt denies any leaking of fluid or lady partsl bleeding. pt denies ctx's. pt reports (+) fetal movement today.history in progress.
here's an example of my arom note:
immediately prior to artificial rupture of membranes, fhr baseline ____, moderate variability, spontaneous accelerations to the ____'s and no noted decelerations. upon completion of arom no umbilical cord is palpated, small [color=gray](or scant or moderate or large) amount of clear, watery consistency, normal smelling amniotic fluid. fhr baseline ____, moderate variability, spontaneous accelerations to the ____'s and no noted decelerations. contractions every ____-___ minutes, lasting ___-___ seconds. abd palpates soft between contractions. contractions palpate mild.
here's an example of my 2nd stage note:
rn remains at bedside throughout 2nd stage; assisting patient with pushing; evaluating fetal monitor strip. pushing efforts adequate. patient states pain relief from epidural remains adequate. room set up for delivery. dr ___ [color=gray]and nicu aware that patient is pushing. will notify when needed for delivery.
here's an example of my delivery note:
spontaneous lady partsl delivery of viable [infant's sex] @ [time] over an intact perineum by dr ____. [color=gray]1st degree lady partsl/perineal laceration (or 2nd degree [color=gray]episiotomy)[color=gray] repaired. infant vigorous at birth - - spontaneous cry, pink with bilateral acrocyanosis of hands and feet, placed on pt's chest to begin bonding after fob cut the cord. tactile stimulation & bulb suction of nose and mouth of infant done on pt's chest. apgars 8/9, remains in room with mother. to warmer, footprints done, id bands applied. infant wrapped and given to pt. nursery notified of infants delivery time, apgars, and that the infant is of "average size." nursery nurse on her way to assess infant.
what do you ladies think of my notes?

wow! that's a lot of charting - must take quite a bit of time. possibly some double, triple charting is going to happen which can get you into some trouble.

you'll get it. it just takes time. :wink2: