Summer is here, and along with climate change, the weather is hotter and drier for much of the world. Wildfires have become more common even in places that have typically not experienced them to any significant degree. If you are pregnant, wildfire smoke from a wildland fire, or even a campfire, could have an impact on pregnancy.
Standard of care is a legal term, not a medical or midwifery one. When referring to the quality of care provided in a situation of healthcare, standard of care is the term of lawyers, not healthcare providers.
Bullying and incivility in midwifery, nursing, and obstetrical practice have been the subject of several articles in the past few years. In 2008, JCAH published a sentinel event alert requiring all hospitals with their accreditation to have a policy in place for the confidential reporting of bullying without fear of repercussions.
Some of the most frequently requested documents from health care institutions in preparation for litigation are Policies & Procedures. An example: Pitocin dosage and management, nursing protocols, electronic fetal monitoring, VBAC, shoulder dystocia, mag and pre-e, preterm labor, oxygen administration and neonates, AND Chain of command. Plaintiffs’ attorneys will compare relevant policies and procedures to the care provided and how it was documented.
Avoid comments in your documentation that can be considered “blaming” e.g. “I gave the order to the nurse but she never seems to listen to anything I say”. Generally avoid recording any negative conversations or disruptive team member behavior. This scenario will make any plaintiffs’ attorney jump fpr joy.
Affirmative Duty Documentation:
- Complications and emergencies requiring management by the health care team, if one exists.
- Timely and appropriate action of the care team.
- Identification of personnel contacted, their title, data reported, changes in patient status, what was requested, and outcome.
If you began your midwifery journey in Nursing School, you are familiar with documentation; paper and electronic. Although medical, nursing, and midwifery documentation was strictly paper for many decades, the current recording of patient care is with the electronic record aka EMR.
