charting tips, decels, etc

  1. I recently attended a course regarding the new NICHD terms/documenting. For example: we no longer should be describing a variable decel by how many bpms it went down or by how many seconds it lasted. Problem is I am a new RN on my unit and the nurses are not following the new guidelines yet. My preceptor instructs me to chart the old way, going into great detail describing every variable, decel, etc. I don't have a good model to follow for how I would chart decels, etc, in the narrative using the new guidelines.

    For instance, if the baseline FHR was 140, mod variability, and at 1931 there was a variable decel - how would you experienced folks chart that in the narrative? Do you chart each and every one, or write a summary of happenings every so often? SG
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    3 Comments

  3. by   Envy
    I might chart it as an isolated deceleration with rapid recovery, if it happens once.(Hopefully it recovered rapidly) If it's repetative,(occurs with every contraction) I would chart it as repetative variable decelerations with rapid recovery and anything I did to improve the pattern and the results of that. I always chart about the company the decleration keeps, the variability.
  4. by   htrn
    I have the same problem with my coworkers. Every conference I have gone to has told us to document a decel as early, late or variable but all of my coworkers go nuts when I tell them this. They refuse to document this way and berate me if I do.

    Soooo, this is what I have been doing. We have a flow sheet that has a space for decels and the appropriate entry is either "P" or "0". I then write in the narrative: FHR baseline 120's, average variability (which is already documented in the flowsheet). At (specific time) FHR decel to 80's X 20 seconds with immediate return to baseline. OR "FHR baseline 120's, average variability with FHR decel to 80's beginning 30 seconds after the beginning of a 60 second contraction, decel lasted 50 seconds with return to baseline of 120's over a 30 second period of time" Heck of a lot of verbage that could be easily charted as: "Late decel at (time) to 80's lasting 50 seconds with 30 second recovery".

    If it is a strip in which I have variables over and over again, I may chart "FHR variable decels continue as earlier described".

    Always chart in your narrative what you did about the decels. Pt turned to L/R side, O2 at 10LPM applied, pitocin decreased, MD notified, etc... ALSO, ALWAYS chart when the MD came and looked at the strip: "MD at bedside, EFM reviewed, no new orders (MD instructed writer to leave pitocin at current rate). Remember, it is your job to notifiy the MD of anything out of the ordinary - let them rant, rave, yell, scream, roll their eyes at you, etc... Then tell them "I just have to make sure that you are aware of...." then document that you made them aware of whatever, and be specific.

    Probably more info than you were looking for, but good luck.
  5. by   HappyNurse2005
    WE have boxes "variability" "acels" "decels" "interventions for decels" etc and we click on teh appropriate one. ifyou click "variable" under "decel" a box pops up wanting to describe it.
    I'd say "down to 80, 30 sec duration, spontaneous return to baseline" the baseline, variability are all clicked on under other boxes,but completely visible right there, therefore, no need to mention it in the note about varibable. any interventions taken can be clicked on right there, too.

    also a spot to click "md reviewed strip"

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