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Wednesday
May312006

Charting

I've long charted narrative. I've tried to SOAP (Subjective/Objective/Assessment/Plan), but I am a chatty girl and it doesn't work very well for me.

In talking to midwives around the country, however, I am learning that narrative might not be the best idea. I've been tapping into my CNM friends and hearing from others how things are done and I think I am going to change some things.

The newest thinking is Less Is Better. Apparently, every word is scrutinized when it comes to charts and licensing boards. While I don't live in abject fear of the licensing folks, it would be good to limit the liability where I can without compromising the woman's safety and autonomy.

So, I typically do about 13 prenatal visits if the woman comes in during the early first trimester. I hand out a slew of papers the first visit for the woman and her partner to bring back the second visit. I have two piles - one to keep, the other to bring back. In the bring back pile are the consents, diet sheet, financial forms, agreement to allow me to keep statistics and other various pages. The stay home pile includes comfort measures throughout pregnancy, anemia worksheet, info regarding prenatal testing (if it is coming up soon) and how to contact me information.

Each prenatal takes on its own flavor - certain things need to be discussed (testing, vitals, etc.) - so perhaps if there was a way to simplify that aspect, that would be good.

I don't think I am explaining that well enough.

At about 12 weeks, we begin talking about the AFP/Triple Screen. I learn what they know and get an idea of whether they want it or not. If they know nothing about it, I encourage them to read through the government materials and read on-line and I will share my own thoughts if they want me to.

In the AFP time frame, I learn what their choices are, have them sign the appropriate consents (state forms) and then we either draw it or not. (By far, the majority of clients choose not to do it.)

Then, when we get towards the 23rd week or so, we begin the whole thing all over again with the diabetes screening. I make a note about the discussion and what mom knows and then will re-address it with her decision at the appropriate week's appointment. If mom knows she doesn't want a certain screen or test, I still make one more cursory request about the test at the appropriate time - just to cover my butt.

So, if I always talk about these things at those certain weeks' visits and I want to minimize my charting, what about making a Standard 12 Week Visit sheet and have that as part of my office protocols/standards? This seems to be what some are doing and it is intriguing to me. So, charting might look like this at 12 weeks: Week 12 discussed - M refuses AFP - 0 comp - RTO 4 wks

Hmm... seems so damn short!

In talking about this recently with my apprentice, I was trying to figure out what to do about women who refuse things like GBS testing, but want to see how things unfold in labor regarding antibiotics. How do I do that in 10 words or less?

Week 32 discussed - M refuses GBS - will consider abx in labor

Okay, 11 words.

So, in labor, I am told to take a picture of the facts and write that down. Not describe the moaning or the music or anything. Just facts.

M ^ to void - BP 112/72 - T 98.2 - P 76 - FHT 130-140 (B awake) - sipping H2o

Hmm... this will certainly make my paperwork shorter!

However, what about the mom who comes in to tell me her husband is having an affair and she is terrified of an STD. She shares so many details that I might normally sterilize a little, but in the interest of not forgetting what she said, I would write things down in the chart notes. Instead, I am being told to make use of stickies. So, my apprentice and I obtained some big honkin' stickies that we can narrate on, yet remove if need be because they aren't part of the technical part of her care - merely the social aspects. Voila! What an idea!

I am re-vamping my charts, taking things out that I don't want there anymore, putting some things in that are prn instead of blanket and setting things up for when I need something prn that I haven't given out in the past (how to help your daughter breastfeed your grandson, for example). I have so much STUFF available; it is foolish not to use it.

I know this chart post will evolve and I look forward to others sharing their thoughts and ideas with me about how they do things.

I can't believe I have been charting for over 10 years and I am still trying to get it right!

While we're on the subject, does anyone not in the hospital electronic chart?

Reader Comments (7)

I, too, am struggling with charting, however I am on the opposite spectrum as an Intern Midwife just learning. I tend to write *everything* down. I justify it by knowing that the mother is going to get a copy of her entire chart at the end of her postpartum period, and I think she might like to know what she was dreaming about at week 36 or where her traveling husband was at week 21.

I'm fascinated, though, by the concept of charting informed consent. A senior midwife in my state recently explained that I don't have to have my clients sign off on every little choice they make, be it GBS testing or GD screening or whatever. I simply need to chart that we discussed the issue and indicate what the client's choice regarding the issue was. Boom! How easy could that be?

It makes me nervous, though, because I am concerned about what would happen if my chart were to be pulled for review by the state. How much will be enough? How much will be too much? What are the right words/terms to use and does it matter if it's all in plain English?

I think charting is going to be something that I will always be perfecting as time goes on. I can't imagine that I will have it all down by the time I am licensed.

Thanks for the interesting post! I love your blog!

May 31, 2006 | Unregistered CommenterAnonymous

charts with this stuff on them so you check them off or not and then notes for anything extra- like s/s of UTI/ dip negative UA sent to lab. - uti protocols discussed-
because of my legal status for years I hated to write anything down. every piece of paper is evidence- and if you aren't legal it is all evidence that is bad for you. -- some moms kept their own records like bp and other findings...

June 1, 2006 | Unregistered CommenterAnonymous

Anon 1: I wonder if there is a way to write the woman's story for her, but not have it in the chart. As a writer, I absolutely get the story-telling facet we can provide, but is that our role in the midwife seat holding a chart that might be seen in court?

I, too, just learned/realized that we don't have to have the parents sign every informed consent we offer. When it was pointed out that docs don't have a mom's signature for every single thing, I thought, "duh!!" Even in the hospital when they say, "you'll have to sign a refusal for that," they rarely, if ever, bring something to sign. It is merely charted. I suppose that is enough for us, too?

I was asking another midwife how in the world a mom was supposed to sign an informed consent if she was in the pool (temp going up, FHTs climbing, yet she doesn't want to get out) - wouldn't that be absurd?

What level of refusal would need to be signed? The situation mentioned above? Or a mom refusing to transport with twins or breech? Or do we simply chart that, too. How come this is confusing?

Isn't it weird to chart thinking of others reading what we wrote?

Anon 2: Thank you for sharing your very difficult history with charting. I can't imagine how strong you must be to REALLY consider whatever you write would end up in court.

And yes, I know my blog would also be court material. *sigh*

June 2, 2006 | Unregistered CommenterNavelgazing Midwife

for a while we used some portable cards that were developed for migrant workers- the card had basics- bp, fundal height, place for heart rate ( by the way have you seen docs charting heart rates or just the word present?) pulse, small check off areas for labs..

June 2, 2006 | Unregistered CommenterAnonymous

Interesting how the midwifery community always writes the HR and such. In the hospital (in birth), they don't have a measurement unless a pulse oxymeter is on. Charting temps, FHTs and BP would be required, yes? They are indicative of fetal and maternal well-being.

So the question begs... should we scour doc's charts to see how to chart? Do docs go to charting school? I know nurses have a minute and a half of charting - all I learned I learned from Varney's Midwifery and experience (not so much).

Good points, all.

June 2, 2006 | Unregistered CommenterNavelgazing Midwife

I have a CNM friend who does home birth and she has a PDA she keeps some info on- she was talking about how to secure electronic charts-- to be HIPPA compliant --- but i haven't seen her using her lap top at appointments.
it is a consideration-- far more legible if I were typing... but how would you prove you didn't change it?

June 2, 2006 | Unregistered CommenterAnonymous

All our midwives (we have seven and two birth centers) use electronic charting that I have developed. I say I because I am the one who put it together but in truth the design and testing was the work of many midwives in and out of our practice. We just started marketing it and have gotten really positive feedback.

We have a demo file that you could have, enter some data and play around with if you like. Just email me and I can get it to you.
Fernando

August 3, 2012 | Unregistered CommenterFernando Gallardo

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