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?