FIVE Things to do for Quick & Accurate Midwifery Charting
Whether electronic or paper charting in your midwifery practice, good charting practices are a must for all those legal, billing, and providing good care reasons. The question is, how do we get better at it?
ONE: Administrative training and oversight is key
I know, I know…who wants MORE administration? Keep in mind that while every provider needs to learn how to chart accurately, it is important that administrative actions support and guide providers. Put the effort in here so that it is quicker and easier in the client visit.
Whether you are your own boss or you work with a large team, it is essential for everyone to know what to expect and to follow the same processes. Administrators should seek to:
- Standardize what the providers need to enter
- Enforce accurate and timely charting
- Update procedures when chart review, case review, or CABC guidelines indicate
- Train staff on how to use the EHR
- Use reports based on chart data
TWO: Use templates
Decide upon a general format and content for every provider to follow when charting an encounter. So no matter the experience or training of a provider, the practice can make sure care is provided to the practice’s standard. Why does this matter?
- Increase accuracy, completeness, and timeliness
- Reduce omissions or mistakes
- Reduce frustration and time associated with charting
- Help teach students how to chart well and according to your policies
- If practice-wide changes need to be made, just update the template and everyone is now ready to go
Example 1: You might like to chart your labor assessments one way, but your way might not meet CABC standards the birth center has to follow. For example, CABC now requires that the maternal heart rate be measured and documented when FHT are taken. If your template automatically prompts you to answer this, your charting is correct.
Example 2: At initial prenatal visits, and often the second visits, midwives go through so much health history and current concerns with the client, perform full physical exams, order testing, and make care plans. It is hard to get all that charted! If your template automatically prompts you to answer all this, your charting is more quickly completed.
THREE: Develop a system for completing your charting in a timely manner
Ideally we all get our charting done on every client by the end of their visit. This way, nothing is forgotten and the chart is up to date for any other providers who need it. When that doesn’t happen, how can we ensure good charting?
Every provider should develop a workable system for themselves that values timeliness while balancing other demands on their time. Remember: leaving incomplete charting is never the right choice!