TheMidwife’sStory:DoesYourChar7ngReflect

WhoYouReallyAre?

KarenHays,DNP,CNM,ARNPMAWSSpringConference

May6,2011

THEMIDWIFE’s

STORY:

DoesYourChar,ng

ReflectWhoYou

ReallyAre?

LearningObjec;vesPhotos&Cartoonsremovedforthisprintedversion.• Discusshowthemidwife’sdocumenta7onofclientcaremeetstheneedsofatleast5interestedpar7es(inaddi7ontothemidwife)whodependonthecharttobeaccurate,complete,&7mely.

• Describeatleast3differencesbetweenchar7ngbyprimaryproviders(MDs,MWs,ARNPs)&char7ngbyotherhealthcarepersonnel(RNs,assistants).

•  Iden7fyatleast4keyaspectsofthecontentofachartnotethatshouldbeincorporatedintoprofessionalpeerrevieworincidentreviewtoassistindeterminingthequalityofthemidwife’scare.

What’sthePoint?“Documentcarefullysothatyourac2onsarejus2fiedandyourprocessfor[midwifery&]medicaldecision‐makingisdiscernable….”

CarolynBuppert,ARNP,JD(2011)

WhoElseMightReadTheMidwife’sChart?

Andwhataretheylookingfor?• Othermidwiveswhoshareclinic&/orcoverage

• Consul7ng/ReferralMDs&hospitalstaff

• Midwiferystudents

• PeerorIncidentReviewers• JUAPrac7ceReviewers• DOHBirthCenterReviewers• Clients&theirfamilies

• WAStateDOH– MAC(LMs)– ND,RN,ARNP,etc.boards

• A_orneys– Defense–foryou– Plain7ff–fortheclient

• HealthInsuranceCompanyAuditors

• CriminalJus7ceSystem

YourChar,ngStyleProvidesVisual&ContextualCluesastoWhatKindofHealthCarePrac,,onerYouAre

•  Independentdecision‐maker,whoprac7cesunderherownauthority(withinascopeofprac7ce)

vs.

•  Dependentstafforpersonnelwhocannotmake“medical”diagnosesorimplementaplanofdiagnosisortreatmentwithoutorderorsanc7onbyotherlicensedhealthcareproviders.

Providervs.PersonnelChar;ngProviders

(MD,ND,DO,ARNP,LM,PA?)

• Decision‐makingrevolvesaroundtheassessment• Thereforechar7ngrevolvesaroundtheassessment• Responsiblefor– direc7ngplanofcare– assessingeffectsoftheplan– followinguponallclientissues,treatments,no‐shows– integra7ngholis7cpictureofcaregivenover7me

Personnel(RN,CNA,birthassistant)

• Decision‐makingrevolvesaroundanepisodeofcare• Char7ngrevolvesaroundtasksassociatedwiththatepisodeofcare• Responsiblefor– carryingoutinterven7ons– assessingeffectsofinterven7ons– passingtasksontonextperson

Providervs.PersonnelChar;ngProviders

ReasonforvisitInforma;on:Subjec;ve–client’s

experiences&perspec7vesObjec;ve–physicalexam,labs,ultrasounds,observa7ons,…

Assessment:Diagnosis,ICD‐9,Summa7on,Evalua7on,ProfessionalJudgment

Plan:Usually1entryforeachdiagnosis+rou7neteaching+7meun7lnextcontact

Char,ng:InfoAssessmentPlan

Repeat(integrate)

PersonnelData:Subjec7ve,Objec7ve,

‘NursingDiagnoses’,ProviderCarePlan

Plan:Taskstoaccomplishduringtheepisodeofcare

Evaluate:Canonlyrecorddata

Char,ng:splitupbetweengraphs,

checklists,&briefnarra7venotes

Report&PassOn

Providervs.PersonnelChar;ngProviders

ReturnPNVisitat32wksS:Feelswelltoday.c/oheadacheyesterday

–wentawayw/1doseTylenol&sleep.c/odysuriax2d,nofever,nobackpain.Babyac2veqday.StartedCBE–likesit.

O:Seeflowsheet–allWNL.Urinedip:1+proteinuria,1+leukocytes.NoCVAtend.

A:32wkgest,doingwellexceptpossibleUTI.

P:1.ReviewedBirthPreplist.2.Rev’ds/sxPTL.3.Rev’dFMawareness,callifdecreased.4.CCUAtolab.Disc’ds/sxUTI&pyelo.

Rec’ddoublefluidintake,cranberrycapsules.ConsultiflabindicatesUTI.

Clientwillcallin3dforlabresults.5.RTCx2wk,soonerprnconcernsor

problems.

Personnel*

32wks:Clienthadheadacheyesterday,nonetoday.TookTylenol,slept–nomoreH/A.StartedCBE&likesit.Painfulurina2onx2d;deniesfeverorbackpain;noCVAtenderness.Urinedip1+protein&leukstoday.CCUAtolab–clientwillcallforresultsin3days.Ifresults+UTIconsult.Inthemean2me,willdoublefluidintake&takecranberrycapsules.Revieweds/sxUTI,pyelo,PTL,birthpreplist.Disc’dFMawareness&tocallifdecreased.RTCx2wk,soonerifconcernsorproblems.

*Journalar7cles&con7nuingeduca7onmodulesthatfocusonchar7ngforRNsdonotincludeacompletepictureofhowindependentHealthCareProvidersshouldchart.

ProviderChar;ngIt’sfinetouselanguagethatfeels

moreauthen7ctothemidwiferyprofession,oryourpersonalprac7cestyle.

Buttheorganiza7onoftheprovider’schartnoteshouldremainfairlystandard,withtheassessments&ac7onsreadilyapparent.

Subjec;veaka‘Client’sexperiences’,‘Woman’sperspec7ves’

Objec;veaka‘Exams&tests’,‘Midwife’sobserva7ons’

AssessmentakaDiagnosis,Impression,Appraisal,Summa7on,Midwife’sEvalua7on,ProfessionalJudgment

Planaka‘Ac7ons&Teaching’,‘Today’s&FutureAc7vi7es’

Providervs.PersonnelChar;ngProviders

ReturnPNVisitat32wksClient’sExperience:Feelswelltoday.c/o

headacheyesterday–wentawayw/1doseTylenol&sleep.c/odysuriax2d,nofever,nobackpain.Babyac2veqday.StartedCBE–likesit.

MWExam:Seeflowsheet–allWNL.Urinedip–1+proteinuria,1+leukocytes.NoCVAtend.

Impression:32wkgest,doingwellexceptpossibleUTI.

Teaching&Plan:1.ReviewedBirthPreplist.2.Rev’ds/sxPTL.3.Rev’dFMawareness,callifdecreased.4.CCUAtolab.Disc’ds/sxUTI&pyelo.Rec’d

doublefluidintake,cranberrycapsules.ConsultiflabindicatesUTI.

Clientwillcallin3dforlabresults.5.RTCx2wk,soonerprnconcerns/problems.

Personnel

32wks:Clienthadheadacheyesterday,nonetoday.TookTylenol,slept–nomoreH/A.StartedCBE–likesit!Painfulurina2onx2d;deniesfeverorbackpain;noCVAtenderness.Urinedip1+prot&leukstoday.CCUAtolab–clientwillcallforresultsin3days.Ifresults+UTIconsult.Inthemean2me,willdoublefluidintake&takecranberrycapsules.Revieweds/sxUTI,pyelo,PTL,birthpreplist.Disc’dFMawareness&tocallifdecreased.RTCx2wk,soonerifconcernsorproblems.

ProviderChar;ng:Lotso’Bits&Pieces

• FirstPrenatalVisit• ReturnPrenatalVisits+/‐checklists;+/‐formalizedscreening(nutri7on,depression,sexuality,…)

• ExtraVisits(E&M–separatebilling)

•  Intrapartum&Newborn

• Postpartum/NewbornVisits

•  InformedConsents

• Labs,ultrasounds,etc.– alldated&signed• Contract,Financialstuff,etc.

Thechartisalegal/businessdocumentseparatefromyou&itisconsidered‘factual’evidence.

ProviderChar;ng1stPrenatalVisit&1stLaborAssm’t

• ClientID–name,age,GP,occupa7on

• HxofCurrentPregnancy–Planned(ornot),LMP,concepdate,EDD,prevcare,pregnancys/sx,toxicexposures,…[ForLaborAssm’tthisischangedtochar7ngtheProblemList]

• Da7ng–prenatallyifU/Salreadydone;alwaysincludeinlabornote

• Medical/SurgicalHx–numbered,dates,currentmeds

• Allergies(+reac7ons)• FamilyHx–HTN,diabetes,congenitalanomolies,etc.

• OB/GynHistory–Pregnancies,Paps,BCM,STIs,reprosystemprobs,lacthx

• Psych/SocHx–rela7onship(DV),familyissues,psychdx&whomanages,ea7ngdisorder,ETOH/drugs,homeless,…

• PhysicalExam–V.S.,height,general,pelvic.[ForLaborAssm’tthisincludesFHR,EFW,fetalpresenta7on,cervicalexam,amnio7cfluid,…]

• Assessment–Alwaysincludes“Appropriateformidwiferycare”

• Plan–teaching&wri_eninfogiven,informedconsentsdone,warningsigns,labssentorplanned,nextplannedcontact(clinic,telephone,…)

ProviderChar;ng:1stPrenatalVisit,1stLaborAssm’t,L&DSummary

• Summarizeallinfointooneorganizedprogressnote–demonstratesthatyoupulleditalltogether&wereabletomakediagnoses/assessmentsbasedonthisdata.Makesyourthoughtprocessesovert.

• Mostimportantdiagnosisfor1stPNVisit&Ini7alLaborAssm’tis“Appropriateformidwiferycare.”

• ThesetemplatesaresimilartohowOBsandCNMschart–importantinfoisallin1place&inafamiliarproviderformat.Alsodocumentsyourfamiliaritywithimportantaspectsoftheclient&yourthoughtprocesses.

ProviderChar;ng:1stPrenatalVisit

MAWSdoesn’thaveachartformtopromoteanintegra7venoteforthe1stPrenatalVisit(?)

Thevisitcanbewri_enfree‐handoroffatemplate(printedwithblankstofillinbyhand,orinaWorddocument)

ProviderChar;ng:LaborAssessments

TheMAWSLaborFlowchartformdoesnotpromoteadequateprovider‐levelchar7ng.

ProviderChar;ng:Delivery(Birth)NoteTheMAWSLaborSummary&Newbornchartformsdothispre_ywell.

LateEntries&Correc;ngErrors•  LateEntries–  OKtodowithinafewdays–  Iden7fyitasa“LateEntry”withtoday’sdate&7me,thenrefertothedate

ofservicethatyouareamending.• Correc7ngErrors–  drawalinethroughtheerroneousinfo+ini7al&dateattheendoftheline

• Nevereveralterachartateryoulearnofanykindofclaimorinves7ga7on.Thisisagainstthelaw–acrimeinsomestates.Ifyouhavemoreyouwanttosay,dosoverballywithyoura_orney.Be_ertonotwriteanythingdown.

Checklists•  Greattouseasreminders&todecreasenarra7vechar7ng.

•  Eachitemmustbedescribedinaprotocolorprac7ceguideline,especially

– teaching– consents– warningsigns

•  Itemsmustbedated&ini7aledwhenimplemented.

“TelephoneMedicine”•  Katzetal.(2008)– Reviewed32lawsuitsderivedfromtelephonecalls(mostfrominternalmedicine,OB,peds).60%paiddamages.Averagepayout$519,000.

– CategoriesofErrorsthatcontributedtodamages:1.  Poordocumenta;on88%

2.  Faultytriage84%‐failuretoiden7fyseriousness,failuretocommunicate

3.  Lackofpolicies&protocols38%‐droppedmessages,delayedresponses

4.  Coveringanotherprovider’scalls28%‐nopriorknowledgeofpa7ent,nochartavailable

TelephoneChar;ng–Same!

T.C.date/2meInfo:Subjec;ve–client’sexperiences/perspec7ves Objec;ve–infofromchart(alwaysgesta7onalageorwkspp),

howvoicesounds(goodmood,nervous,crying,…)

Assessment:Diagnosis,Summa7on,ProfessionalJudgment,Evalua7on.OKtosay“Possible”“Probable”“Differen7alDxis…”

Plan:1. ImmediateMWorMDcontactorNeedmoreinfo(BPcheck,ultrasound,FMcoun7ng,etc.)orItcanwaitadayormore…2. Warningsignstocallbackfor3. Timeun7lnextcontact(&whowillcontactwho)

Char;ng:InfoAssessmentPlanRefertoT.C.innextclinicvisitnote?

PeerReview&IncidentReview:Whattolookfor

1.  Chartnotesstartbyframingthecontextforthevisit(exceptongoingintrapartumnotes).

2.  ThenewOBvisit,eachprenatal/postpartumprogressnote,&labor(re)evalua7onsq1‐4hoursincludeanAssessmentbasedonsubjec7ve&objec7vedata.

3.  ThePlanfollowslogicallyfromtheAssessment&includes7meofnextcontact.

4.  Nextplannedcontactisexplainedifitdidnotoccur.

5.  Allvisits,intrapartumassessments&phonecallsarepromptlydocumented(ifnot,it’sexplained).

6.Checklistsarebackedupbyinforma7onspelledoutinprotocols.

7.Noevidenceofaltera7onoforiginalchartentries.

ComputerChar;ngh_p://getprivateprac7ce.com

•  abc•  8910

Communica;ngwithComputers&Phones

• 1stobtainwri_enclientconsent• Email–encryp7onforiden7fiedpersonalhealthinforma7on(PHI)

• Tex7ng–cryp7ccodes?• Facebook,Twi_er–wrieenclientconsentofphoto&text(&anyoneelseinthephotosornamedintext)

• CloudStorage–encryp7on

ConclusionsYouronlyotherop7ontochar7ngistovideotapeyourselfduringallclinicalac7vi7es.

ChartlikeyouareanindependentHealthCareProvider,becausethatiswhoyouare.Thestoryyoutellshouldreflectyourabilitytoassessyourclient’shealthstatus.

“Documentcarefullysothatyourac2onsarejus2fied&yourprocessfor[midwifery&]medicaldecision‐makingisdiscernable….”

CarolynBuppert,ARNP,JD(2011)