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.
During the course of a vaginal birth, a baby's shoulder can get caught on the mother's pubic bone, preventing the body of the baby to proceed down the birth canal for delivery. When this occurs, it is the result of shoulder dystocia.
All events that are associated with a shoulder dystocia must be carefully recorded in the medical record. Appropriate documentation allows an accurate record of what happened during the delivery, especially for attorneys and experts to review retrospecitvely, but also for reviewing your own experience.
