We talk about documentation so much in Labor & Delivery. So...so...sooooo...much. But newsflash: if your care isn't great and there's a bad outcome, no amount of documentation will help. But, if we use documentation and befriend it, then it can be one more tool to help us provide excellent care.
So what is the standard of care when it comes to documentation? While there’s lots of guidance on what to chart, from AWHONN or your facility, there is almost no set standard on when to chart. Thus, we are left with our old stand-by for standard of care: “What a reasonable and prudent nurse would do”. What does that look like? My best advice for charting in a manner that is both timely and realistic is to think about breaking documentation into 3 categories: real time, near time and late. I’ll explain each of these and what should go into each category. For a downloadable guide, click here.
Real Time: Charting that occurs in the patient room, at the time the care is given or assessment made. Your hospital or manager has most likely been pushing this for awhile. And yes, the closer to the time the care was given, the more thorough and accurate it will be. But plenty of times I’ve seen nurses give up and think “Well, I didn’t chart in real time, so it doesn’t matter now when I chart”. They end up charting late A LOT. If you want to improve the timeliness of your charting overall, focus on making sure a few key things are charted in real time, and leave the rest for our next category.
Includes: meds, vitals, I/O & pain assessment, EFM assessment, notification of providers for critical elements.
NEAR-Time: Charting that is given within an hour or so of the time being given*. This is where I came up with the term “near time” because it’s not exactly in the moment but it's pretty close and very likely to have the thoroughness and accuracy of real time documentation. This should be the vast majority of your documentation. Think of it as that sweet spot between timely and realistic. Or another way to think of it is that Near-time is Real-time documentation’s cool older cousin who’s been around the nursing station a time or two. It accounts for the normal busy-ness of a shift.
Includes: shift or physical assessment, notification of providers for non-urgent, non-critical reasons, labor care, education. Basically anything not in the real time category.
*Near-time is a term Jen definitely made up, but feel free to use it ;)
Late: Charting that is later than a reasonable, similarly trained nurse would chart. There is no set legal definition. Often a facility will have a procedure on how to make late entries but not what constitutes late documentation. Let’s look at a few examples and see what you think:
Your patient delivers at 1200, has a retained placenta that requires a D&C, then hemorrhages. At 1500, you have to go back and make a few entries from the end of second stage, but the OR charting and your QBL was done in real-time. Do you think those entries, 3 hours after birth, from the last 30 minutes of second stage are late or not? Probably not. As an expert, I’m looking at the overall pattern and the story I see here is that, up until that point, the charting was thorough and timely. I also have been in that exact same situation in my bedside practice, so as an expert it’s clear that the nurse has directed her attention to the emergency and keeping the critical information (like monitoring the bleeding and intervening) up to date in the record so other clinicians have access to it. That seems like what a reasonable and prudent nurse would do, doesn’t it?
Needing to catch up some documentation from Big Emergencies after patient stabilization doesn’t really need an explanation in the chart. They’re rare and we get it. But there’s a difference in needing to catch up charting from the emergency or the time just a little before and needing to catch up charting from hours preceding the emergency. It’s prudent to be on top of documentation when that happens for two reasons. First, with real or near time charting, you give yourself the chance to catch things that may be developing, possibly avoiding the Big Emergency. Second, after a Big Emergency it’s hard to remember everything from before, and can leave the impression that the nurse really wasn’t being all that vigilant.
Your patient arrives at 1200 and delivers at 1530, after a Category 2-3 tracing and operative vaginal delivery. Nothing is charted until 1830, after recovery, when all of the documentation is done. Do you think this charting is late? Probably. Sure this situation occurred in a narrow time line, but to be unable to chart anything, including the assessment of the tracing which was worrisome seems below what a reasonable nurse could do, especially one who had many years of experience. Do you see how, even if the charting is done the same amount of time later, it can leave a different impression?
Charting can be a safe guard (dare I say friend?), from the situations like the second example. Charting really makes you focus on that piece for a moment. I’ve seen so many cases with EFM assessments charted after the delivery of hypoxic infant. The nurse, when she sits down to chart, is often realizing for the first time that the tracing was, say, tachycardic with minimal variability and lates for over two hours. It’s likely if she had assessed and charted in real or near time that she would have caught it and intervened to improve the tracing and oxygen status of the fetus or advocated for a change in plan of care. However, since she was merely glancing out of the corner of her eye or listening, she didn’t give herself that chance.
So there you have it! It’s not just what you document, but also when you document. Is documentation the #1 thing that keeps patients safe and you from being involved in a malpractice suit? No. Nope. Probably not even in the top 3. But it does help, by giving you the chance to focus on the important elements in a timely manner, reasonable & prudent nurses give themselves a chance to see issues developing and intervene early.
To learn more check out my course Reasonable & Prudent, including more on simplify your approach to documentation.
And here's that download again!