For those of you that haven't run away, thanks for reading on. It's you open minded midwives I need to talk to anyway!
There's a good case to be made that perfect documentation is not as crucial as we all think.
A bit of backstory to this post: I looked after a lady a few months ago. I'll just refer to her as 'triplet lady'. As you can imagine, she was a lady who needed lots of care after her caesarean.
In fact, she had a PPH post Caesar which needed emergency care on the ward and then hours of input to help with breastfeeding with some very cute but seriously demanding newborns. I also had 2 other mums to take care of.
I got incredibly frustrated at the amount of documentation I was doing, to the detriment of my lady's care - I'm not joking, at one point I was almost in tears because I was so fed up of spending my time writing things. There were some dark, dark moments on that shift.
And then I had a lightbulb moment: I suddenly realised that documentation, however well it's done, will not save me from being sued. What might is really good care - and to have time to do that, I need to stop wasting it on paperwork.
Now I have a brand new attitude to documentation; and within minutes of implementing it, I was so happy to be back on form as a midwife that I almost cried again - but this time in a good way.
I've done a load of research for you so you too can avoid documentation headaches. Don't document yourself into burnout!
Notes were started in healthcare to pass information onto the next carer. However, it's now much more about covering ourselves in case of getting sued.
Legalities: If you do get into a malpractice litigation situation, documentation acts as evidence. It's best to make sure your documentation is legally credible, and there's an excellent resource on how to do this here.
However, verbal and witness statements will also be taken into account in court. And even if your documentation is near perfect, there's no guarantee it will protect you. If you write 'lady A is in bright mood' instead of 'lady A appears to be in bright mood', this one word change could be a pivotal piece of evidence of your court case.
Clearly, we can educate ourselves and do the best job possible - but in a busy ward situation, we just can't document perfectly, every time, in a way that is immune to being picked apart in court!
This brings me onto my next point.
Remember my triplet lady?
I made a conscious decision to spend more time with the woman than with the paperwork.
I built up a solid, professional, caring relationship with her.
I didn't do substandard documentation. It was just about legally credible. But I didn't write an essay, and I wasn't a perfectionist.
Things I left out included:
- I gave paracetamol 1g (I 'merely' wrote it on the drug chart)
- The buzzer being within her reach (though it was)
- The first blood pressure I did during the PPH (couldn't remember it, and we had plenty of baseline obs from theatre, and I documented the one 30 seconds later)
- Her bed bath. I just put 'is clean and comfortable'
The thing is, that lady isn't going to remember me and say 'Wow, those blood pressures that little midwife recorded were just perfect. Beautifully presented. She was so proficient!' or 'The way she phrased that bed bath in the notes was so meticulous. How wonderful'.
I didn't assume that there was a court case just waiting to happen in her room. The time I would have spent chasing tiny details, I spent with her.
Instead of 'if you didn't document it, it didn't happen', I think what is far more true is: 'poor practice and lack of communication are likely to be the underlying factors in litigation - and no amount of documentation will ever cover that up' (Morris 2005 MIDIRS Midwifery Digest).
There was a really interesting study done in 1997. It audio taped patients visiting doctors for a first consult. These tapes turned out to be really good predictors of the doctors getting sued, i.e. lay people listening to the tapes later could predict with some accuracy the court cases that later arose.
The ones who were less likely to get sued didn't have any better outcomes and certainly didn't document more.
- offered more education
- solicited patient's opinions, checked their understanding, and encouraged patients to talk
- spent longer with their patients
- used more appropriate humour
(Journal of the American Medical Association)
There are loads of other studies that say similar things, for instance, Moore et al (2000) found patients thought their physician was more skilled if they were better at communication and respect as well.
They didn't have better outcomes. They didn't have better technique. They just gave their patients more respect!
So back to my triplet lady. Was the best way to avoid being sued to have stellar documentation? No. In my opinion, even if something does go wrong with her care or outcomes she'll remember that a midwife was with her, observing how she was feeling, addressing her pain, making her feel safe.
She'll remember that her triplets only cried for the minimal amount of time before feeds because her midwife was in the room to help.
She'll remember I acknowledged her emotions and concerns about her PPH, I empathised, reassured her, and explained.
And after all, isn't this what being a midwife is about? I'll be damned if I don't enjoy my career because I'm panicking about litigation and documentation, and it's doing no good to the women in my care also!
I do the minimum documentation to protect myself. And then I follow the evidence (and my gut instinct) that I will protect myself more by spending my time looking after the women in my care.
Yes, the rate of litigation is rising. Yes, it's scary. But no, as far as possible, I will not let it affect the way I look after women. And ironically, it appears that this attitude in itself will protect me from litigation.
Am I wrong? Or does this research and evidence ring true to you too?
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