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Best Practices in Charting: Lessons Learned from the 4.0 MANA Stats Validation Project

by Courtney Everson, PhD by Gina Gerboth, MPH, RM, CPM, IBCLC
  • Duration: 1439 Mins
  • Credits: 1 CERP, 1 R-CERP
  • Learning Format: Webinar
  • Handout: Yes
  • Origin: MANA 2017

Accurate charting is a critical midwifery skill. Charts are legal records and are important for a multitude of reasons. Charts provide a narrative of each client encounter. Charts are critical to interprofessional collaboration during times of consult, referral, and transfer. Charts add clarity when there is a question regarding the events of care, especially during litigation or regulatory investigation. Finally, charts can assist researchers in obtaining valid data as part of perinatal data registries. Limitations of midwife charting were identified during the 4.0 MANA Stats Validation project. This session is based on an analysis of charts received during the project. The purpose of this session is to provide recommendations, skills, and tools that will help midwives to improve charting efficiency, clarity, and consistency. Session content will apply to both paper charts and electronic health records, and will include: interdisciplinary trends in health records; the legal, regulatory, research, and clinical implications of health records (the “why” of charting); recognizing critical, chartable information that should be included in all clinical encounters (the “what” of charting); tips for writing clear, useful notes (the “how” of charting); tools for the appropriate incorporation of essential information into the record (the “where” of charting); the appropriate timing of entry (the “when” of charting); and identifying the appropriate persons for chart writing and review (the “who” of charting). Resulting improvements in charting will support future validation studies of the MANA Stats perinatal data registry, protect midwives and clients during courses of care, and help advance midwifery professionalism.

Learning Objectives:

Objective 1: Explain the importance of validation in clinical care research;

Objective 2: Describe trends in electronic health records;

Objective 3: Identify common abbreviations and conventions in charting;

Objective 4: Compare legal, clinical, regulatory, and research implications of charting;

Objective 5: Deconstruct midwife (personal and professional) biases in charting;

Objective 6: Analyze confidentiality and privacy protections for the client during charting;

Objective 7: Identify critical, chartable information throughout the childbearing year;

Objective 8: Describe HIPAA requirements during charting;

Objective 9: Create inclusive forms for charting with diverse communities;

Objective 10: Explain appropriate personnel during charting.

Categories: Midwifery