Documentation

[rnaturcervix]

How often do you document FHT'S and ctx info on your pts? Antepartum, labor, on pit, etc.

[klone, MSN, RN]

It's been a few years, but IIRC, antepartum is documented however many times there was an order to get FHTs. For many women it was just BID or QID. Latent labor, hourly. Active labor q15m, 2nd stage q5m. Pit, same as active labor.

[rnaturcervix]

Thanks for your reply. For the last 13 yrs, we've documented q 30 min for active labor and pit. 2nd stage has always been q 5min. Recently, a new manager changed our policy to q 15 for active/pit, and I feel like I can't stay caught up with my charting and be hands on with my pt. Of course it doesn't help that we're super busy due to neighboring hospitals closing down, and we've just started a new documentation system that I swear was invented by Satan himself!

[TexasCourgette]

At my facility we chart q30 for labor without pit, and q15 for pitocin, and q5 when pushing (regardless of pit or not). We also have an intermittent monitoring protocol for patients who are unmedicated (no pit, or fentanyl, or epidural, or anything), where they're monitored 20 minutes/hour, and then you end up charting FHTs only on that 20 minute strip.

For antepartums, it depends on their monitoring orders--if they're being closely watched, then chart FHTs/CTX q hour, if they're on NSTs, then just the NSTs.