Documentation

TallPoppy · #1 (**permalink**) 10-Nov-2007, 18:41

Please discuss all your concerns and thoughts and debate your views regarding documentation here.

Duel · #2 (**permalink**) 10-Nov-2007, 18:45

I like documentation.. Its one thing I can do lol.. Its always commented in my assessments that my documentation is to a high standard! T'is because I have had fab mentors that are BRILLIANT at documentation to teach me!!

chow46 · #3 (**permalink**) 10-Nov-2007, 22:25

It is so important to document everything. My first job was in a prison where inmates were often taking medical professionals to court to sue for wrongdoing, so I really got a good education on that. Since, I'm kinda shocked to see how other nurses document. We would get residents back from the hospital and the nurse's notes would have hardly anything in them at all. I had no idea what their stay was like! Proper documentation has gotten me out of many a tight spot and it's not something I tend to cut corners on.

tracyb · #4 (**permalink**) 10-Nov-2007, 22:43

I write essays for documentation lol, I'm so thorough to the point where I def go OTT but hey why not? I think its better to write lots than barely write anything-cos like you say Sasha you nener know when you'll be called into account, sad tho it is.

Angelcake · #5 (**permalink**) 15-Nov-2007, 13:53

I love documentation. It often is the only time I get to sit down. But what really gets on my goat is how some people can write so illegibly. Handwriting should be a module in the course. I have worked with mentors whose handwriting looks like somebody tied a pen to a rat's tail and let it run around the page.

chow46 · #6 (**permalink**) 15-Nov-2007, 17:51

lol, angelcake, I agree! The doctors are the worst here, not sure there, but some nurses have horrid handwriting. How in the world can I take over care, I have no idea what you did!!

smwife · #7 (**permalink**) 15-Nov-2007, 18:48

Originally Posted by Angelcake

I love documentation. It often is the only time I get to sit down. But what really gets on my goat is how some people can write so illegibly. Handwriting should be a module in the course. I have worked with mentors whose handwriting looks like somebody tied a pen to a rat's tail and let it run around the page.

Hahaha!

SO true

wannabe · #8 (**permalink**) 15-Nov-2007, 20:36

I think time spent on documentation is mostly time stolen from the women. It makes me sad to see midwives rush to their documentation, almost as a relief from the effort/intensity of being with the women, which I have seen happen.

I would like to see something like a modified version of All Wales Pathway for Normal Birth more widely used, where all obs in normal active labour are noted on the partogram, dispensing with the need for extensive essay writing in the notes.

TallPoppy · #9 (**permalink**) 15-Nov-2007, 21:22

Originally Posted by wannabe

I think time spent on documentation is mostly time stolen from the women. It makes me sad to see midwives rush to their documentation, almost as a relief from the effort/intensity of being with the women, which I have seen happen.

I would like to see something like a modified version of All Wales Pathway for Normal Birth more widely used, where all obs in normal active labour are noted on the partogram, dispensing with the need for extensive essay writing in the notes.

I agree. When I firsted started my training I was shocked to see the amount of paperwork that was required and in duplication. We do however have a partogram with obs listed, so duplication has stopped there and in the notes.

I recall being really surprised how much notetaking occured during the second stage, I would find myself split between caring for the woman and recording what was happening... I understand that the litigation culture has meant we have to protect ourselves and the women by keep these 'excessive' notes, it really saddens me that this means time is taken away from caregiving..

TallPoppy · #10 (**permalink**) 23-Apr-2008, 23:33

Are you guys asked to write some care in the notes in a different colour? I worked with one midwife who wrote VEs in red but another sho said you must only ever write in black...