fetal heart monitor strips as a legal document

fiestynurse · Aug 15, 2004

...

Mazzi · Aug 18, 2004

I work labor/delivery w/ Trace Vue. We are now being told to throw away all of our paper monitor strips. As you said this is considered a legal document. Are we safe in throwing them away post delivery?

finallyRN · Aug 18, 2004

We do computer charting on our unit and the strips are being stored in the computer however we still are saving our paper monitor strips. Computers are still not a perfect system if memory is lost so I think it is still important to keep the paper strips.

KellyLynn · Dec 6, 2004

I sure hope they are recording those paper strips on microfilm or computer prior to throwing them away.

Allaroundnurse · Jan 21, 2005

Is there some kind of back up? If the attorney has someone who knows about L&D they are going to ask about the strips. If they or their information can't be produced that is going to put up a very large, bright red, with blinking stars flag. Your hospital attorney should have this covered already and it should not be a problem. Just to make sure that when you go to bed at nite and rest your wee little head on that nice soft pillow-you don't wake up screaming-talk to your unit manager, make a policy and make sure everyone follows it. If you all document on the strips that documentation better be somewhere else too!!!

Mazzi · Jan 29, 2005

TraceVue down loads strip q18 sec. So all is recorded in the system and can be pulled back up at any time. But since we do write on the strip, does this make it a legal document?. Along with the strip we also are charting in trace vue.

palesarah · Jan 30, 2005

we're going from paper charting to OB Trace-vue in a couple weeks. Currently we document on the strips and flowsheet, but when we go to computer charting we're no longer going to be able to chart on the strips as the hospital will not be keeping them. They are going to be backing up the computer system weekly, and discarding the paper strips after the computer-archived strips have been successfully backed up to optical disk each week. If we write on the strips, they become part of the medical record and we cannot discard them.

It's going to be a big adjustment period for everyone! (Overall, most of the staff are pretty tense about going to computer documentation but I'm looking forward to it- I have horrible handwriting! And I like using computers anyway)