Tuesday, October 21, 2008

Charting

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.

2 comments:

Radical Midwife said...

I tend to chart a ton! I sometimes feel self-conscious about it, but I'd rather have multiple pages of prenatal notes, since my memory isn't all the reliable. lol!

Tiffany said...

good job. there is nothing more irritating that looking at a chart that is far below par.