Charting
There are two types of records: source oriented and problem oriented. Source
oriented record keeping uses traditional narrative charting. Problem oriented
records use SOAP or SOAPIER charting. SOAP(IER) is an acronym for Subjective
information (reported by the client), Objective information (observed by
the practitioner), Assessment (drawn from the data), Plans (for action related
to the problem), Implementation (of plan), Evaluation (of plan), and Reassessment
(of client's needs). In this kind of charting, each entry is on a separate
line, labeled with the midwife's initials.
The legal requirements are very specific. All entries must be legible and
done in black ink so the chart can be easily photocopied. Errors must be
corrected by drawing a single line through the notation so it remains legible.
Mistakes may not be obliterated by scratching, blacking, or whiting out.
The word "error" is written above the mistake and initialed by
the person making the correction. The correct information is then written
beside or below the error.
Each page must be marked with the client's name, the date, and the legal
signature of each person charting on that page. All entries must be initialed
by the person entering the data. Each entry on the labor record must also
contain the correct time. In narrative charting, you must never leave a
space or partially blank line. Draw a line through the blank area and then
initial at the end of the line.
Never chart a procedure until it is done, but chart it immediately. If your client refuses care, notate that along with an explanation. Charting requires that a midwife use her skills of observation. We talk about "looking" for symptoms, but we should also be listening, smelling, and touching. As long as a midwife is with a client, she should be continuously observing her, actively watching and listening at every opportunity. We can often learn as much by what is not said as by what is said.
Charted information may be overt (obvious), covert (hidden), and either
objective (measurable by an observer) or subjective (known only to the
client). Overt information includes such observations as the client's
fundal height or degree of pitting edema. Covert information could include
an asymptomatic vaginal infection or the client's hemoglobin count. Objective
information includes a client's blood pressure or the fetal heart tones.
Subjective information could be the client's report of vaginal itching,
burning upon urination, or nausea.
The ABCs of charting consist of Accuracy, Brevity, and Completeness.
You cannot be judgmental ("can't handle pain"). Rather, write
"client moaning with each contraction." Avoid vague terms such
as "large" ("passed large clot of blood"). Be specific:
"passed blood clot approx. 5 cm in diameter." Be sure that abbreviations
are proper and commonly used. Be brief: complete sentences are not necessary.
Be complete: Review, assess, and explain results of care given.
- Lani Rosenberger, Midwifery Today Issue 33
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Midwifery Today's Online Forum
Any recommendations as to how to get a laboring mom up and out of the
bed? I recently attended a first-time mom who reported that her contractions
were so much stronger when she moved around that she just wanted to stay
put, semi-sitting/reclining on her tailbone. She hated just going to the
bathroom, so walking around a lot to get the baby to engage was certainly
impossible. She was afraid of her pain and wanted to avoid it. She ended
up with an episiotomy - no surprise there! I'd like to know what to do
should this situation occur again. How do you get the mom to realize that
it's really better for her to move around, in spite of the fact that it
hurts?
To share your thoughts and experience, go to Midwifery Today's Forums.
Question of the Week
I've met a lady who is wishing to have a VBAC. Her previous c/sec was
due to complications arising from cholestasis. She is currently around
19 weeks gestation and so far she has no sign of itching. There seems
little available natural treatment or preventative ideas that we've come
across. However, the threat of its return is looming within the literature
(high risk of recurrence). Being a VBAC mum myself, and able to acknowledge
the obstacles that can exist, I'd dearly love to hear of any experiences
that carers have used to combat cholestasis.
- Anon.
Send your responses (with "Question of the Week" in the
subject line) to:
E-News Readers Speak Up on Charting
My charting is short and sweet. I make out an index card
for each new mom. Top left is EDD (estimated date of delivery); top
right, blood type; and name of other midwife involved. Then name (and
partners), address, phone number, then directions to their house. Across
the bottom, names and ages of other kids. On the other side, turned
lengthwise, I keep notes on each visit. Always, date of visit; gest
age/fundal ht; fht; V.S. & urine dip results, then any other pertinent
data like, "started hawthorn," "quickening," "cx
posterior & to the right," "encouraged more protein, grn
leafies & squatting ex." Usually each visit fills up one or
two lines, so the whole pregnancy fits on one card. During the pregnancy
I keep these cards in my purse, filed by due date. After the last postpartum
visit, I file them alphabetically by last name. I have another file
of my copies of MANA stat forms, filed by date.
- T.W.
I work as a hospital based midwife and take the subject
of charting very much to heart. I have already had the misfortune to
be caught up in a court case, and it was the precise charting that was
the lynchpin for my eventual acquittal of the (ridiculous) charges.
However, when I am caught in the middle of an emergency,
accuracy of charting is one of my first priorities. As we train midwifery
students in our hospital, they, or even the new graduates, need to learn
about obstetric disasters, but it can often be a Catch 22 as they might
not always be able to be productive, and therefore "in the way"
in a delivery room where the emergency is happening.
What I like to do in a resuscitation emergency for example
is to put the student with the notes and a pen in the room. She is then
involved, but not out of her depth. She can chart every action, at every
correct time and she can observe and learn from the proceedings without
being overwhelmed or flustered. Her input is then a valuable contribution
to a retrospective view of the events. Recently we had such a situation:
the student charted at the time of the resuscitation but the resident
doctor did a retrospective charting on the same piece of paper. Gross
errors were seen in the Rmo's notes in both time, Apgars and actual
events. It's easy to see which will be viewed as the more correct were
it to be investigated.
- Robin Moon
Sydney, Australia
The most important thing to remember in charting is the
belief that "if it wasn't charted, it wasn't done." I have
recently gone through an investigation with my professional governing
body--nursing--and it really opened my eyes to the realization that
six months down the line, when they are asking you hundreds of questions,
the reality is that you just don't remember and you really do rely on your chart to refresh your memory. Questions are asked such as How was
the lighting? What kind of flashlight did you use? One that you hold?
One that straps on your head? Believe it or not, I just could not recall
until after the questioning was over and I had checked it out with my
partner.
It is important to document who did what. The second midwife
usually does all the charting when the primary midwife is at the perineum
but this charting should be checked and perhaps initialed by the primary
midwife after the birth, e.g. perineal compresses applied by so-and-so,
apprentice; head delivered by so-and so, apprentice; tight nuchal cord
clamped and cut on perineum by so-and-so, primary midwife; PPV initiated
by so-and-so, primary; EMS called by so-and-so. It all sounds so minor
but in reality, six months down the way, it is very difficult to recall
who did what. We were so used to just flowing together, doing what needed
to be done by whomever, but in reality, when they (the employers, governing
bodies, lawyers, etc.) are investigating, they ask these questions and you need to be able to answer them. Quite frankly, I may have gone to
the extreme now after this extremely difficult experience but I keep
the client's chart open and document everything I see, hear, feel, assess,
hear the mom saying, the ambience in the room, the lighting, everything.
It's also important to clearly document all discussions
with the parents; informed choice is extremely critical in today's midwifery
practice and must be documented: all the options you've given her, the
benefits, the potential side effects, her response or decision. I had
been a nurse for 30 years prior to this incident, doing homebirths outside
the law for the last seven years. I had a lot of unlearning to do in
the area of informed choice. I was used to seeing doctors doing things
to women and then telling them what they'd just done. At the time of
birth, we were unable to hear the fetal heart tones for the last 40
minutes and relied on scalp colour and fetal movement. We didn't tell
the parents of this because we did not want to worry them. That is a
huge no-no in this process of informed choice. In hindsight, they may
have chosen to go to the hospital for further monitoring if they had
known. This was a very important lesson to learn. I am just very happy
that the baby is doing fine one year later. But it has been hell (mentally
and physically) throughout this process. I hope this will help prevent
other midwives from going through what I've just gone through.
- Gisele Fontaine, CPM
QUESTION OF THE QUARTER for Midwifery Today magazine
Mamatoto: Motherbaby
How can midwives best facilitate the bonding process of motherbaby in pregnancy, birth and postpartum?
Deadline: March 31, 2001
Send your response to:
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Switchboard
Know a strong woman? Helping empower one? If you haven't already done so,
please forward this issue of Midwifery Today E-News to one or two of your
friends or business associates. Thanks so much!
Suzanne Arms to research in Holland for upcoming video and new edition
of book: Suzanne and homebirth midwife (CPM) Sally Kane from Colorado
will be travelling to Holland, Paris and Germany March 20th of this year
to research midwifery and the details of maternal-child health policy
and care. We're focusing on Holland and would appreciate any contacts
in Amsterdam in public health and also help financing the on-land travel
costs. Tax deductible. For more info: contact Sally at Sallyk@paonia.com.
====
I'm a midwifery student at CWRU in Cleveland. I 'm looking for resources
re: herbal preparation for cervical ripening and labor induction. So far
Lisa Summer's article and Barbara McFarlin's are the best I have found.
I want to find midwives who have practice guidelines, or protocols for
their use of cohosh, red raspberry, evening primrose and castor oil. This
all started with a look at Cytotec, which is used a lot here. I'm not
close to birth centers, and most midwives in this area practice in a hospital/medical
model. If anyone is willing to just talk (even if you want to remain anonymous)
I would love to hear about what you are doing and how, and any resources
for knowledge about herbals that you think are good.
- Laurie
Reply to: Matthews_laurie@hotmail.com or lhm2@po.cwru.edu
====
I am O+ and my husband is A- blood group. My first child is A- and within
six hours of his birth, he became severely jaundiced and needed a blood
transfusion due to ABO incompatibility. I was informed by the physicians
that subsequent children I have will experience this problem unless they
are the same blood group as myself. The problem may be mild or severe
as in the case of my first child. Is there an alternative to blood transfusion
in the more severe case and the mechanism of ABO incompatibility? I am
due to have my second child in approximately five weeks.
- Anna
====
In conjuncture with the article in O this month, there is a message/post
board at Oprah's website asking for our opinions about homebirth. My highest
hope is that it will be inundated with requests to do a show (series?)
on homebirth. There isn't another avenue that would reach so many people
at once. If you share my hope, please post a message. This is an especially
opportune time since she is actually asking us for our opinions. Maybe
if she gets a bazillion replies she'll do a show!!! Click here to read more or visit their message boards to post!
- Charisse Lawson, doula
====
I am interested in fetal malpresentation during labor, especially relating
to maternal position changes, the how, when, and where of them, and if
they positively affect the c-section rate. I have been able to find very
little on this topic in the major medical and nursing databases. Can anyone
give me some direction on finding relevant research on this topic?
- Colleen Kelly, RN, L&D
Reply to: ckelly3@wpo.it.luc.edu
====
Is it true that prostagladin gel is derived from pig semen?
- Amy Jones
Henderson, NV
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