Writing on Fetal Monitor strips

CEG · Aug 22, 2008

I don't know about everywhere else, but we just throw the paper strips away following delivery (assuming there are no issues) and the computer strip is archived. So although some of our nurses do write on the strip, it is mainly to go back later and make sure they get everything entered in the computer record.

Elvish, BSN, DNP, RN, NP · Aug 22, 2008

I write on the strip things like 'toco readjusted' or 'pt coughing' etc. That's about the extent of things. Keep in mind, I don't do labor and delivery. I do antepartum on the floor, so am either running an NST or have mom on the monitor because she's having some issue. May have her on there a while but not more than 2 hrs or she goes to L/D. What really annoys me is when the docs (interns, usually) come along to review them and circle what they think are decels...... :eek: STOP!!!

For the love of Heaven, please do not do that!

cassioo, RN · Aug 22, 2008

There isn't a "law" about writing on strips but if you are saving the strips those can be called into court...if they are on computer that along with notations on the computer can also be pulled.

kenny b · Aug 22, 2008

I write on the strip things like 'toco readjusted' or 'pt coughing' etc. That's about the extent of things. Keep in mind, I don't do labor and delivery. I do antepartum on the floor, so am either running an NST or have mom on the monitor because she's having some issue. May have her on there a while but not more than 2 hrs or she goes to L/D. What really annoys me is when the docs (interns, usually) come along to review them and circle what they think are decels...... STOP!!!
For the love of Heaven, please do not do that!

Could you please tell me why? Thanks in advance!

Regards,

Kenny B.

cassioo, RN · Aug 22, 2008

tell you why for what? why write on the strip...to document what was happening at that moment to cause that reading on the strip.

why don't circle things...it puts a big bullseye on the strip for a lawyer.

kenny b · Aug 22, 2008

tell you why for what? why write on the strip...to document what was happening at that moment to cause that reading on the strip.
why don't circle things...it puts a big bullseye on the strip for a lawyer.

Yes, why not circle things. Thanks for the clarification.

Rgds,

Kenny B.

hoppermom3 · Aug 22, 2008

Many of our nurses write everything on the strip - then use the strip to do their charting later. We are all paper charting. Personally, I prefer to keep my chart on a clipboard at bedside, and write directly into the chart. Otherwise, I am actually writing everything twice - once on the strip and once on the chart.

Our older nurses were taught to circle decels and initial them. When I took Intermediate and Advanced EFM, I was taught to never do that.

mom2michael, MSN, RN, NP · Aug 23, 2008

We have computerized charting (along with a a paper strip) and we keep it all for 21 years. I keep being told to not document on the paper strip (ever) and to only document via computer. My guess is the rationale might be a huge red flag to the ol' lawyer if my paper chart has writing and my computer chart doesn't reflect that particular issue or if my paper strip doesn't agree with the computer strip (as far as my note).

I'm thinking consistency is the issue where I work rather than any laws or an official stance. They want all their nurses doing the same thing each and every time they chart. Less liability that way.

teriadn2004 · Sep 3, 2008

Thanks for your comments - we are opening a brand new unit in a brand new hospital and my NM just wanted to know what others are doing. Our understanding is that medical records will be scanning our strips into the record in addition to the recorded EFM. Seems like duplication to me too.....?

Baby1nurse · Sep 4, 2008

Take a Michelle Murray course. If you are doing your documentation electronically, she tells you to NEVER write on a strip because then it becomes a legal document. Once you document on it, you cannot throw it away, it should become part of the patient's chart. We don't run strips anymore unless we are precepting and need it for a teaching tool or if we see something that doesn't show up well on the electronic strip but we never write a patient's name on it, nor do we document on it. If we do, we put the patient's stamp on it and it becomes a part of the chart. You can only toss the strip if it doesn't have anything written on it. If you have to document on something and do not have time to do it electronically, use the nurse's all purpose documenting - the paper towel! Or the well known tape on the leg or writing on the bed sheet. Just don't write on the strip

SmilingBluEyes · Sep 4, 2008

First and foremost, NEVER EVER write anything that obliterates the fetal heart tracing or contraction tracing. If y ou must write on the strips, be sure you write in blank spaces, leaving the tracings clearly legible. Make sure your writing is legible too, and up to the minute in currency.

Many hospitals are going to computer charting systems, like "QS"--- that make writing on monitors strips largely unnecessary (or even non-recommended). BE SURE whatever you do, you are within hospital and unit policy in charting, whether on paper or in the computer.

Agree with the above suggestion to take an advanced fetal monitoring class, such as what Dr. Murray or Lisa Miller, CNM offer.

http://www.proedcenter.com

It may help to have a look at that above site for leads/information regarding such courses-----also Dr. Murray has an excellent FHM book and workbook you might find of use. I think you can find that book also on the above site.Also consider becoming a member of AWHONN:

http://www.awhonn.org

I highly recommend this, as well. Anyone in OB/GYN or newborn nursing would do well to join AWHONN---lots of benefits and information when you do!

I wish you Good luck.