Re: Documentation of lates

[Guest guest]

I have heard that you chart a late as a late...ect, but as an older nurse I've seen the name of decels come and go. Since legal action can sometimes take years, I prefer to chart what I see. Something like...FHT's down to 90's over 30 seconds with peak of ctx. Rapid onset and rapid return to BL., STV +..... (this is obviously a variable decel), and then go on to describe what I did for it and what the response was. I also chart exactly what I tell the MD and what if any orders he gave. Some times an entry like "no orders received" speaks volumes and also give a good idea of what is happening if you have to go to your chain of command if the MD isn't responding like he should. JMHO

Deb

"The fingerprint of God is often a paw print." Chernak McElroy

[OBnurses] Documentation of lates

How do you all handle your documentation of lates? I was always told to never label them as lates. Only describe them, and describe them I do. You can't document enough. One of our newest nurses recently told me that our educator told her that you should chart it as a late. She said she was told that you have to chart what you see, but you chart what you see by describing it. I think that describing it and its relation to the contraction would be better than labeling it. Just curious what you all think and any legal aspects.

[Guest guest]

We were also told not to use LATE ENTRY when charting.

She was referring to late decels. I document them as lates if they are very obviously late, other wise I describe them.

Carla

Attached Mommy to Tanner 7, 4, & my waterbaby Tatum 1

[Guest guest]

AWHONN teaches in it's fetal monitoring classes that you need to describe and interpret a pattern for what it is. Late decelerations are ominous but not as ominous as a nurse who can't interpret them. AWHONN also states that if you put on a monitor you must be capable of interpretation. More and more lawyers are watching for nurses who refuse to interpret. Lawyers claim that non interpretation of clearly defined FM patterns is due to a lack of competency and therefore the nurse should not have been working in an L & D anyway.

It seems that we can't win for losing.

[Guest guest]

AWHONN also states that if you put on a monitor you must be capable of interpretation.

Do they interpret that as meaning a tech can't put a pt on a monitor because she can't interpret the tracing? In our unit we have 2 techs who will place the pt on a monitor so they can get a tracing while until the nurse can get in the room. The nurse is still responsible for the strip. Just curious, because I haven't done L & D for 4 years (am in nursery now) and my monitoring skills are way rusty....Laurie

[Guest guest]

In a message dated 3/27/2004 3:30:33 AM Eastern Standard Time, kemper1974

writes:

> Do they interpret that as meaning a tech can't put a pt on

> a monitor because she can't interpret the tracing?

Yep! It caused a lot of static in my hospital, but techs can no longer apply

monitors. They don't say it in so many words, but they also frown on LVN's and

fetal monitoring. They do not allow LVN's to attend there fetal monitoring

classes.