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Wednesday
Dec222010

Charting: Whose Truth?

A brilliant piece came out December 2, 2010 in Birth Sense. “Five Reasons Your Doctor/Hospital/Midwife May Not Want You to See Your Medical Records,” caused a flood of trying-to-read-my-chart stories to fall from my brain into a jumble of scribbled-on papers, too many of which making no sense whatsoever. 

When my niece was entering Medical School, she had to present about a trillion pieces of documentation, one of which was her entire life’s medical records. Of course, we pored through them, reading her history through the eyes of care providers. While many of the entries were barely legible, one doctor in particular wrote in a hand that knew nothing but straight lines with an occasional twitch of the pen upwards. The overseeing committee considered sending her back to the HMO to find the doctor and ask him what he’d written. The notation was from ten years ago! 

I’ve read charts and written in charts for many years, even studying charting manuals to make sure my notations were medically and legally accurate. (A couple of books I've used were Mosby's Surefire Documentation: How, What, and When Nurses Need to Document and Charting Made Incredibly Easy.) But, through reading what other health care providers have written, I am continually reminded that much of charting is quite subjective. This fact alone should (in my opinion) comfort many a woman crying over the stupid things someone wrote in her chart. All sorts of things can affect what the provider (nurse, doctor, midwife, chiropractor, etc.) chooses to document. If they’re having a crappy day, their attitude colors the descriptions of what’s in front of them. A happy midwife might write (in shorthand, however): Patient concerned about weight gain. Whereas a cranky midwife might write: Weight gain excessive; counseled patient. All sorts of life situations can affect the tone of a provider’s notes: marital satisfaction, health, ingrained beliefs about certain races or gender… even religious prejudices or, what many of us encounter, disagreeing with the doctor’s advice. 

My own kids’ records are a study in annoyance on the part of the nurses (mostly). I would not let them take my kids’ temperature rectally; this was the standard of care in the 80’s. All over their charts: Mother refuses rectal temp. Sometimes with a giant exclamation point to reiterate their disgust that I dare defy their protocol… and near-shoving me, trying to get me to do what they wanted to do. I didn’t care. I wasn’t going to risk having my children’s bowels perforated. Tough if you don’t like it (was my thinking). 

When it comes to our maternity records, it can be scary to see what someone thought about us, how they perceived our choices and actions. Reading cold observations like “Patient refuses to take prenatal vitamins” can be disconcerting when the reality was the ones you tried made you throw up. 

The worry and fear can really take hold when we order our prenatal, labor and delivery and postpartum records. Reading what you lived through can be surreal; what’s on the paper all too often totally disagrees with a woman’s memory of her birth. What annoys me greatly is the medical record is considered The Truth, is used in court as the Be All and End All of what happened at the birth. Can I tell you the crap I’ve read “documenting” a birth I’d doula’d and knew the details of very clearly? I’ve seen exaggerations of a woman’s pain level, nasty comments about a family member’s behavior, mis-timings of when a mother started pushing and more. What must a mom think reading her chart without someone to let her know, “This is bullshit.”? 

Birth Sense’s post gives examples of the challenges women face when they want to get their records… how people lie about who the chart belongs to, charge them huge fees to obtain their records (I had to pay $50 to get my records from Tristan’s hospital birth) and women having their charts physically ripped out of their hands. I encourage women to find a friendly midwife who will order your records for you and perhaps going over them with you (for a consult fee, of course). If you want your records without the consult, no problem; they are your records. 

When you get your chart, please remember the subjectivity of what’s written in there. Post-cesarean moms in particular half close their eyes as they read what’s written about why they had a surgical delivery. Over and over I’ve heard moms tell me, “But they said <fill in the blank>! They didn’t tell me there was <fill in the blank>.” The chart can reassure a mother wanting to have a VBAC (was there a single or double layer suture [which, by the way, isn’t charted quite often, so the assumption is it was a single layer suture… the conservative route], was the baby acynclitic or was there a nuchal hand… variations not likely to repeat with the next baby. The chart can also bring the memory of a birth crisis crashing over a woman’s body and mind. If there were near-death experiences with the baby or dramatic hemorrhages for the mom (for example), reading can mean re-living; take exquisite care of your Self as you open the folder. 

Along with the “the doctor didn’t tell me that,” comes “They are wrong!” Twice I’ve seen the gender of the baby written incorrectly. Not that it’s funny, but I chuckle thinking about that chart being used as an exhibit in court; is it an accurate account of what happened? Or was the person that was too oblivious to note the gender correctly also too oblivious to record the mother’s overdose of pain meds. 

So, if you do get your chart, as you read, take what’s said in there with a salt lick (as opposed to a grain of salt). If you find notations that are flat out lies, you can petition to get the chart amended. If you don’t do that, you might not be able to convince another provider that what’s written is, in fact, false. But, even if the exaggeration/lie/mistake remains in there, at least you know the truth and a sympathetic provider will certainly take your words under advisement. 

All of this does not imply that every chart has patent lies or glaring mistakes written in them. We’re taught to be as objective as possible, but, as humans, that isn’t always possible. I'd even say the great majority of records I've read have aligned with what the mom recounts as well. And there are times when mom's memory differs from the chart because the memory was out of context to the whole picture and once it's put into context, the woman's able to revise her knowledge about her own case.

But it can be healing for women to hold their charts in their hands. Empowering, even. So, if you're ready, order your chart, read it and learn what you can about your specific case. Ask questions if you don’t understand something and then move forward with the new knowledge you have about your Self and your baby's birth. As is often said, "Knowledge is Power!"

Me, charting after a birth. Photo by Nova Bella de Lovely. 

References (13)

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    - Navelgazing Midwife Blog - Charting: Whose Truth?
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Reader Comments (24)

Great post!

Not only do providers often make chart notes impossibly illegible, they use language that is deliberately vague or misleading. Failure to progress ("I have a dinner party/golf game/dance recital/holiday/weekend and need to get this woman delivered"), fetal distress ("We pitted the hell out of her and she's already got an epidural, so let's just get this baby out"), poor maternal condition (she won't let us give IV hydration and we really don't know what a non-medicated working hard laboring woman looks like). I could go on.

Subjective judgment is not accurate charting nor is it able to be accurately interpreted or justified. The fact is that charts are often deliberately vague in order to protect the provider. This practice is blatantly unfair and potentially damaging.

December 22, 2010 | Unregistered CommenterErika

I had to laugh when with my 2nd pregnancy the reasons given for the 1st c-section delivery was cephalo-pelvic disproportion when I never got past 4cm, never pushed and so was never tried. It really felt like the justification of the c-section was weak when they wrote that, and they wanted to shore it up, even though I consented (sorry, pitocin labor without pain control is torture especially when placing an epidural took hours and a lot of vomiting) and felt justified with the direction we took for his delivery. It feels like not only does it depend on the mood of the one charting but also how tired they are and their outlook for the future (as in, is this going to bite me in the butt later?).

December 22, 2010 | Unregistered CommenterEthel

Wow, living in Canada I have had no problem accessing my medical records at all during my pregnancy. My doctor was more than happy to have me look at them and I have copies of the results of every test she's run on me so far. Of course, I haven't given birth yet so this could easily change.

December 22, 2010 | Unregistered CommenterKimberly

I have only once requested any of my records, and it was at the request of the military, but was rather pleased to find my midwife describing me as "a lovely 24 y/o female..." Lol, I choose to believe that's how all my doctors have described me and therefore have no need to see any other documentation!

December 22, 2010 | Unregistered CommenterDanielle

Interesting post. I read every entry in your blog, although I don't comment. It is my favorite birth blog. I'm an aspiring midwife. I just wondered what resources you were referring to when you said you studied up on charting techniques. Do you have any recommendations?

December 22, 2010 | Unregistered CommenterJen

Good question about where to learn proper charting techniques. I'll add a couple of resources I've used to the original post. Thanks for asking!

December 22, 2010 | Registered CommenterNavelgazing Midwife

I've occasionally thought about requesting the records from my first birth. There are things I wonder about that I didn't think to or couldn't bring myself to talk to the midwife about in the immediate postpartum period, and there are things I struggle to remember or am not sure about. More than anything, it kind of bugs me that I have these blank spots in one of the most significant events of my life.

But then I wonder if I would even be able to understand it if I got it and if it would be worth the money.

And with this post, I question whether it would really answer my questions or just replace my impressions with someone else's impressions. Whose truth, indeed.

December 22, 2010 | Unregistered Commenterchingona

@ Danielle ... LOL! At my 41week visit with my second birth, the student midwife said, about my still being pregnant, "If it's any consolation, you look really cute pregnant." Hope they charted that! "Patient still looks great!"

December 22, 2010 | Unregistered Commenterchingona

Wonderful, insightful, and important words.

I didn't get my charts from my c-section until right as I was changing to a new care provider at 36 weeks in my next pregnancy. Reading that chart was eye-opening. Reassuring. Surreal. Strangely empowering.

But I know too of so many women whose experiences and memories directly defy what they find in their charts. (I'm glad you point out that sometimes, what seems like a cold or callous note is really more reflective of a care provider's mood--or maybe even just the shorthand nature of the note itself.) What makes me especially furious is when women were told that they had a c-section for "failure to progress" and/or that they have CPD and then later discover in their charts that their baby was asynclitic, baby had a nuchal hand, etc.

December 22, 2010 | Unregistered CommenterKristen

You just lit the fire under my butt to order my hospital records and hopefully find out exactly what my EBL was for my "not a hemorrhage" that left my Hgb at 7.2.

In addition, the phrase "take it with a salt lick" rocks my socks. I find it quite a propos not only for chart notes but for much of what women are told about birth in our society.

December 22, 2010 | Unregistered CommenterMegan

Great post, Barb!

The most recent post on my blog, an amazing VBAC story from one of my clients, is a perfect example of the things you're referring to, Barb. This mama (who had a horrendous birth experience w/her 1st baby--manipulation and neglect from her caregivers right and left) was shocked when she FINALLY got her medical records within the first year after her c/sec. (She jumped through hoops to even get her records in the 1st place.) There were all sorts of discrepencies on it, compared to what she and her husband were told. So sad, but like you said, "knowledge is power." Indeed! For that mama, it gave her the power to file official reports with the hospital, the anesthesiologist and the OB. She's a hero!!

December 22, 2010 | Unregistered CommenterDelightfulBirth

As a nurse, it is my job to document what the patient reports (subjective information). I also need to objectively document what I see, hear, feel and smell. (Inspection, auscultation, palpation, and sometimes different odors - which are less objective in my opinion, depending on how well the person can smell different odors.) For instance, I know what amniotic fluid smells like. However, it's extremely hard to put descriptive words to what it smells like. I would probably chart something along the lines of: "Pt reports leaking clear vaginal fluid since 0800. Pt states fluid keeps "gushing out". Pt arrived to L&D with saturated towel in her pants. Moderate amount of clear fluid noted. Odor strongly suggestive of amniotic fluid."

Note that everything I chart in the above example is just straight up information. No personal feelings interjected. That is how we're supposed to chart as nurses.

Here is another way it could be presented, if there was lack of physical evidence of ROM upon arrival: "Pt reports leakage of clear vaginal fluid since 0800. Pt reports small gushes of fluid since initial large gush of fluid. Pt arrived to L&D with no peripad on, with dry clothing. No fluid seen on labia upon inspection. No odor noted."

December 23, 2010 | Unregistered Commenteratyourcervix

I know how charting is *supposed* to be, but I do hope you can acknowledge it isn't always (often?) like that. I've seen too many subjective comments/notations to believe everyone's as ethical and considerate as you with charting.

I *love* reading charts that have notations such as the above, but rarely... RARELY... would I see something that thorough or descriptive.

December 23, 2010 | Registered CommenterNavelgazing Midwife

Seriously? You've never seen anything that descriptive? Wow. Maybe I'm just a Type A when it comes to charting in the narrative. And yes, I do understand that sometimes (too often) nurses/providers do not chart without being subjective of their own feelings.

Sometimes, we do see what is much different than what the woman reports to us. Like, if she comes in complaining of severe pain, but is talking on the phone, watching TV, laughing, etc, then I know that she is not in severe #10/10 pain. In that case, I would chart something along these lines:

Pt ambulatory to L&D with c/o lower pelvic pain and low back pain coming every 3-4 minutes for the past hour. Pt denies any LOF or VB. + fetal movement. Pt reports pain as #10/10. Pt in no apparent distress - talking on the phone, laughing with family present in the room. Not using breathing techniques during contractions. Contractions palpate mild to moderate.

December 24, 2010 | Unregistered Commenteratyourcervix

Great entry. My midwife had trouble getting my medical records from my OB at our first meeting. She was telling me that my OB refused to let her have them because they were confidential property that belonged to the OB's office. It took about 2 weeks of fighting to be able to finally get them. I still haven't read my medical files (I keep forgetting to ask my midwife for a copy of it). My hubby always kept me from reading my file at my OB's office because he said it wasn't my business. My Midwife, has my file with her, in a notebook and she lets me read it. She said that she's got nothing to hide and will let anyone (ie me, her, or ER doc if it gets to that point) read it.

December 24, 2010 | Unregistered CommenterKaia Mireles

Kaia: This is something I forgot to put in the post. Shoot. I might have to go tuck it in somewhere.

Here in CA, it is *not* the law that patients have access to their charts. The information is there and clients/patients are privileged to the MEDICAL information. As a midwife, I keep a flow chart of the absolutes: temp; bp; fhts; etc., But, I also keep a parallel description of what we do and what goes on and what mom tells me. This is a Narrative style of charting and is strongly disfavored anymore. Namely, because the more you say, the more rope you have to hang yourself. I learned Narrative, so it's hard for me to SOAP. (http://en.wikipedia.org/wiki/SOAP_note) SOAP is what most mw's use, as far as I'm aware of. I've tried to SOAP, but I'm kind of chatty, so Narrative is easier for me.

So, if I am asked for a woman's chart, all I am really, ethically responsible to give the provider is the Flow Chart and labs. The Narrative can stay in the original if I choose for it to. If it's a mw, I'll send the Narrative along; with OBs, I usually only send the two "required" sections. I really don't even send labs if it's a past pregnancy they are asking for records of; labs are repeated each pregnancy, anyway. If a lab was wildly out of the range of norm, I would totally send that on.

Back to CA law. So, if a provider asks for a chart, it is a COURTESY for the original chart writing provider to send the client's/patient's chart along. The courtesy in my world is that the chart is sent within 30 days of the request. But, there is nothing in the law that requires a provider to pass on previous information.

Here, it is also correct that the records do NOT belong to the patient, but to the doctor, hospital or clinic... that includes x-rays and sonos.

Here's the Medical Board of California's explanation of the Records Release issue:

http://www.medbd.ca.gov/consumer/complaint_info_questions_records.html

Note that that might be different in different states.

December 24, 2010 | Registered CommenterNavelgazing Midwife

Hm, my OBGYN lets me read my medical records any time (and with no editing, I might add), most of it I've read it while she was writing it, lol. I haven't asked for copies, since I know what's in there, but I know that if I asked, I'd get them... maybe the only cost to me would be the paper they were printed on.

December 24, 2010 | Unregistered CommenterA

I would love to read the records from my csection, but at 63 cents a page, I can't afford it. I did get the surgery report, which details that someone put their hand in my vagina to push my daughters head out the incision. Is that a typical procedure?

December 26, 2010 | Unregistered Commenterferret lady

ferret lady: Email me and we can talk about getting your records for you. Navel gazing Mid Wife at G Mail dot Com (all smooshed together and in email form, of course).

When a baby is impacted in the pelvis, yes, someone does put their hand in the vagina to push the baby back up so s/he can be born via the abdominal incision. I've known it to happen several times; one with a client of mine whose baby was *not* impacted, but the hospital was punishing her for daring to try an HBAC. (The "Forced Cesarean" post here on this blog.)

December 26, 2010 | Registered CommenterNavelgazing Midwife

A positive thing here in the UK is that the woman carries her pregnancy medical records. Literally, she is given a book at her first appointment, of which she is the owner, and she carries it to all appointments and the birth. Great for fostering a sense of ownership and control, and for encouraging midwives to write in a clear way. Not so great if the woman forgets them ;)

December 29, 2010 | Unregistered CommenterHilary

It was interested and sad to review records of with a client of mine whose baby passed during her hospital birth. So many errors, small and large, and despite the fact that she requested her ENTIRE record, the most important pages were missing: OB progress notes and nurse's notes. THAT's where the details lie....not in some "summary." I've encouraged her to "re-request" those records....I hope she does.

January 13, 2011 | Unregistered Commentermomandmidwife

After my c-sec, I was told by several of the staff that I had been given an inverted-t incision, while my o.r. report did not note that at all!

April 5, 2011 | Unregistered CommenterKm

I was sent home from my first birth with a summary of sorts of the birth and initial infant care. The report stated that I'd had an epidural when in fact I'd had no pain medication (except for the pudendal block I was given, without my consent, for the episiotomy that followed, without my consent). I was kinda pissed that they obviously just didn't change the standard option (epdidural). Not sure what my actual records say and honestly for my vaginal birth, I don't really care. As far as I know I'm done having babies but maybe if I have $45 laying around one day I'll order my cesarean birth records and see what those say. Of course I'm not sure I want the trauma that might come from an unexpected surprise. It took my four years to discover that the experienced doctor who I thought had done my surgery (guess all that talk about what HE was going to be doing misled me a bit) had in fact, stood by as a resident did it. Apparently I agreed to that? I'm not sure I want to know any more.

May 18, 2011 | Unregistered CommenterRachel

If you ever do want your records, I'm glad to order them for you. They're free that way.

May 18, 2011 | Registered CommenterNavelgazing Midwife

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