AKA: If It's Not Written Down, It Didn't Happen.
I've been complimented on my charts by senior midwives, let me start by saying that. Yet, lately, as I look back at old charts with a fuzzy memory, I am finding them lacking. I have no problem with charting significant, important events, like exams, vital signs, etc. It is the small things that are often missing.
Once a mom told me that I never told her that Group B Strep could be transient. That it could be negative at 37 weeks and then be positive by the time 40 weeks rolls around. I am certain I told her because I have a "pre-recorded" talk that I say when I give them the test. But it's not written down. Now, I have an informed consent -- two pages long, that they have to sign that stays in their chart. Now I have documentation that they will have gotten all the information.
Another chart I recently looked at didn't have information about phone calls that were made. I need to remember to chart every phone call, even if it doesn't seem important at the time. I also ought to chart rescheduled prenatals, cancelled or missed appts, etc.
I'm training someone new to chart, so it's important I not be slack at this time. Faerylady is an awesome charter. So, I learned from someone who is really good. And I used to work in the medical field myself, for my dad who was a surgeon, and later for a law office organizing and indexing medical records. I've seen some heinous charting come out of big Level III hospitals. Records with faulty times (uh, what time exactly is 26:30???), records with huge holes in the information, records signed off by doctors who were never seen during the course of the labor.
I want to do a better job at charting and be more diligent with getting out the chart after a phone call to record what was said, what was recommended, etc. I should also chart emails.
I have redone my prenatal record sheet to make room for lots of writing. Now I have no excuse.