Pregnant Pt 20 wks How Do You Document?

[RNinTX]

You receive a patient on a med surg or telemetry unit and you learn she is 20 weeks (or less) gestation. She has PIH so you are monitoring blood pressure and perhaps tele monitoring. Management does not care about the fact that your patient is pregnant. In fact they tell you not to even include this fact in your documentation because "the fetus is not viable". Any attempt to encourage transfer to the Women's Center is ignored or refused. Of course this fact IS documented on the admission assessment as the question is posed, "Any chance you might be pregnant?"

Has anyone had this situation in your hospital? If so, how is it handled and how do you document and care for both patients?

Any input would be greatly appreciated!

[ShayRN]

I tend to get my hackles up as soon as I hear management tell me to document or not document something. I would document that she was pregnant, then I would document that my management was informed that I felt she needed a transfer. But then, that is me. They aren't going to do a THING to save my butt, you can be doggone sure I am going to cover it.

[BluegrassRN]

In addition to documenting that she was pregnant (hello, she has PIH!) and that I requested a transfer, I would also document heart tones q shift. We usually request that an OB nurse comes down to do it, though since I worked OB for several years I typically just listen myself.

We don't run a strip or anything, we just listen for a minute or so.

[NickB]

not to even include this fact in your documentation because "the fetus is not viable".

Seriously? This is the most ridiculous thing I have ever heard. If you just pretend she isn't pregnant, than she may be prescribed treatments with no regard to her unborn child. YOU are her advocate, and YOU are the baby's advocate. Remember those two details and then make your decision. We all know you can't just ignore the fact that she is pregnant. If she were 23 weeks and 6 days, would they still be saying the same thing?

[tewdles, RN]

You need to document the facts. Only your documentation will cover your butt when this woman loses that baby...your administration certainly won't be looking out for you...they already instructed you to omit critical information from your documentation. Good for you for advocating appropriately for this woman and her baby.

[MedSurgeMess]

ALWAYS document the facts, not what management or the facility want you to document. As everyone above has said, if it comes to lawsuit time, they will toss you under the bus and laugh as it runs over you! The facility and management only care about saving themselves, they don't really care who gets hurt or ruined in the process. Remember, this is about you and the patient.....

[mandykal, ADN, RN]

as what the above posters recommended, document! take it from my experience, i've had to sit down in a conference room with an investigator from dph regarding my documentation. you can say what you want to say, but if it's not in blk & white, you are liable... fortunately, i was lucky it was all there.

[mamamerlee, LPN]

PATIENT STATES SHE IS PREGNANT. LAST MENSTRUAL PERIOD --/--/--. No c/o related to pregnancy. Or, no cramps or vag bleeding noted. Pt states she can feel the baby moving. ETC.

OF COURSE it must be documented that she is pregnant!!