One of the most blatantly wrong things I repeatedly hear in nursing, that I’ve heard from the time I was in nursing school is “if it wasn’t charted, it wasn’t done.” At one of the AWHONN conferences I attended, I went to a legal issues in nursing session and took away a very valuable message—We do a hundred things a day that we don’t think to chart, don’t have time to chart, or just forget to chart. That doesn’t mean we didn’t do it. It means we didn’t chart it.
I have not been to court (yet!). Working in labor and delivery, it’s hard to escape your career without finding your way in some sort of legal issue. I am sure my time will eventually come. But when it does, I am certain I will feel confident. I don’t care how big they blow up my charting, I don’t care how they speak to me, or what the issue is about. I feel like I have a lot of things going for me. For one, I’ve been a member of my professional organization, AWHONN, since I graduated from nursing school. I consider this evidence that I am vested in my profession, and committed to providing my patients with the best possible outcomes. If anyone were to try to intimidate me, this is what I would tell them.
At that AWHONN conference, in that legal issues for nursing session, one of the most important things I took away were these words: I know I did it, because it’s part of my daily professional practice. So how do I know I did it if it wasn’t charted? Well, I know I did it because it’s part of my daily professional practice. 🙂 How do I know I repositioned her when she was having variable decelerations? I know I did, because that’s part of my daily professional practice. If anyone were having variable decelerations, I would immediately reposition the patient, because I know that variable decelerations are a result of cord compression. That is part of my daily professional practice.
I thought that those words may have been one of the most important things I’d ever heard about OB. I don’t think I’m an expert in anything. And I in no way think I know everything. But I feel like we should all help each other, spread any useful information we come across, and support each other as colleagues and as women, because we’re all on the same road. Our paths may look different, but we’re all on the same journey. So chart defensively. Try to remember to chart what you do. Try to remember to chart everything you do that pertains to maternal comfort (it’s not just all about the meds you give and when the doctor is at the bedside). I always thought that it would be hard to make me look like a bad nurse if I’m constantly talking about everything I’m doing to try to make the patient more comfortable (and I do want her to be more comfortable.) Chart when you’re in the room. And if you ever find yourself in a courtroom, or talking to a lawyer, I hope that you have done everything you can in regards to your own professional development so that no one will ever be able to call into question your professional practice. ❤
Until my next delivery! ❤