Guest guest Posted November 13, 2001 Report Share Posted November 13, 2001 Hey, welcome to the group...any other lurkers out there feel free to pop in and say Hi! BTW, as far as the forms go....geez we have forms for everything!! All our patients preregister between 35 and 37 weeks. They spend one hour with an RN and go over all paperwork, make sure they are "plugged into" all there is, i.e. teaching needs, financial needs etc. W, then update this info each time a patient comes in tot he hospital for anything. If we see them before their "MPS - Maternity Prepared Stay visit, then we pick and choose which information is pertinent to the visit and fill that in. We look to the "governing" bodies to determine which items MUST be completed at each visit and which do not require attention at things like an NST or R/O Labor. A lot of it is judgment. Some of it is plain stupid, like right now it is required that we do a nutritional needs update at each visit and make a referral to a dietitian if necessary based on the answer to the "key" questions. Pretty silly at times. Our forms have all been designed by US!! We do all computer charting. We have done so for about 7 years now. Recently the entire hospital went to computer charting which is a plus for us since we will soon interface and have our labs shoot directly to our OB flowsheets. It's awesome to be able to double click on any report, even ultrasounds from a previous pregnancy and get the whole report. The doctors also have access at their offices now which includes seeing a "real time" monitor strip instead of faxing it to them! After two hours postpartum, most pts are on a clinical pathway in which all charting is done by exception. Our high risk clientele have standards or guidelines for care and are also on critical care flowsheets. They are also narrative and not only charting by exception D/T the nature of the high risk "beast"! Our unit has a nurse practice committee that is responsible for all the revisions, updates etc. They work hard to keep up to date with all the governing bodies such as AWHONN etc. to make sure our stuff is up to date. We also have a perinatal outreach department that services all the "feeder" hospitals. We try to make sure that all the hospitals that send patents to us are in sync with what we do. We have in the last few years required all of them to maintain the same standards and comps for things like EFM, NRP, and PCEP. One thing you have to realize is that one person alone cannot take on this kind of paperwork project! You need to have a few people helping you for sure. I know we were all totally fried when we did this originally, and that was just the beginning of the ongoing revisions required. It took us "years" to get the paperwork right! And BTW (Yes, I'm bragging here!) we had a 100% compliance with paperwork when joint commission, all of our state reviews and HGFA (Not sure if I spelled that one right?)I remember when we first started we were also very concerned about charting by exception AND pathways. We have been assured that it works and over the last years we have proven it clinically as well as legally, (our risk management department includes an "X" OB nurse which has significantly helped us when getting RM approval) We are a "trendy" unit....its kind of fun! (I'm sure that they may be FUN In a sick sort of way! Hahha) SO if you have a specific type of form you are looking for, let me know and I'll see if I can help. Jan Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.