OVERVIEW:
It is essential that midwives know the information that must be included and how to organized it in a way that upholds comprehensive Charting Guidelines.
PART 1: CLINICAL CONTEXT FOR MEDICATION, LAB, CONSULTATION & REFERRAL
RESOURCES:
Basic Medical Key (2017). Chapter 12: Medication administration records and drug distribution systems.
College of Registered Nurses of Manitoba (n.d.) Documentation guidelines for registered nurses.
University of South Carolina. (2014, Dec. 9). General teaching documentation and coding guidelines for consultations. DC-317.
Medicare Learning Network (2020). Complying with laboratory services and documentation requirements.
INSTRUCTIONS:
Review the resources and outline at least 5 influencing factors of content that will be included for each bullet point: (20 pts)
Essential Information on a medication record
Documenting requirements for laboratory services
Interprofessional Collaboration “When we collaborate with our interdisciplinary team members and develop and/or modify the plan of care based on our collaboration, we should document the following:” (pg. 15).
Documentation needs to be included request a consultation, and a referral.
It is essential that midwives know the information that must be included and how to organized it in a way that upholds comprehensive Charting Guidelines.
PART 2: Clinical Context for the Intrapartum
RESOURCES:
Health Education to Villages. (n.d.). Normal labour and childbirth: Managing complication in pregnancy and childbirth. A guide for midwives and doctors. WHO, Department of Reproductive Health and Research.
*Resource refers to birthing person as ‘woman’; MCU supports supporting the personalized gender identity of the birthing personQueensland Government. (2017) Normal birth. Queensland Maternity & Neonatal Clinical Guideline.
*This resource refers to the patient as ‘woman’, please know MCU affirms self-selected gender identity for any birthing person WHO (n.d.). Section 1 Clinical Principles: Managing complications in pregnancy and childbirth. Center for Reproductive Health and Research, WHO.
*Resource refers to birthing person as ‘woman’; MCU supports supporting the personalized gender identity of the birthing personOPTIONAL: Royal Children’s Hospital Melbourne (n.d.) Nursing documentation principles.
INSTRUCTIONS:
Review the resources, (primarily Queensland: starting at Section 3 (Initial maternal [parental] assessment)) and summarize the clinical-situational observations & assessments that will be included as part of the chart/partogram. (45 pts)Assessment: (Section 3) and Diagnosis (WHO)
note initial assessment will determine ongoing care (ex: admit into L&D care, transfer, etc.
First Stage (Section 4)
Second stage (Section 5)Birth of baby (Section 5.3)
- Third stage (Section 6)
- Placenta and membrane exam (Section 6.2)
- Perineal exam: Assessment criteria (Section 6.4)
- Fourth stage: Newborn care and assessment (Section 7.2)
- Fourth stage: Maternal/parental care and assessment (Section 7.3)
PART 3: Outlining Clinical Context of the Antepartum/prenatal Initial Visit
Phelan, S, (2008, Jan.) The prenatal and the initial visit. Glob. libr. women’s med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10107.
Optional: Michigan HHS (n.d.) Maternal [parental] professional visit progress note.
INSTRUCTIONS:
Summarize content that will be reviewed and added to each of the following chart sections. (optional add to Charting Reference Guide, created earlier in course). 55pts
INITIAL VISIT:
Demographic
- Menstrual/family planning History
Obstetric History
- Medical & Surgical History
Physical Exam
Nutrition & Psychosocial Evaluation
- Laboratory Studies
Risk Assessment
Education
- Management Plan
CONTINUING PRENATAL CARE
PART 4: Clinical Context for Newborn/neonate Exam
RESOURCE:
Stanford Medicine (n.d.) The newborn examination, Clinical rotations for students.
INSTRUCTIONS:
- Outline information that will be assessed when reviewing the following newborn body systems: (60 pts)
General appearance
Head
Neck
Eyes
Ears, Nose, Mouth
Thorax & Breasts
Lungs & Heart
Abdomen & Umbilicus
Genitalia
Trunk & Spine
Extremities
Neurological - Links to an external sINSTRUCTIONS:
- Part 5: Clinical Context for Postnatal/postpartum
RESOURCEs:
Blenning, C. E., & Paladine, H. L. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496. https://www.aafp.org/afp/2005/1215/p2491.html - *Resource refers to birthing person as ‘woman’; MCU supports supporting the personalized gender identity of the birthing person*View the source as a pdf to see table 1Contra Costa Behavioral Health (2021, June) Clinical documentation manual.
- Chapter 6.5: Discharge Summary
Optional: Derricott, B. & Crean, H. (n.d.) Postpartum care and complications. Wild Iris Medical Education Inc. - *Resource refers to birthing person as ‘woman’; MCU supports supporting the personalized gender identity of the birthing personNational Institute for Health and Care Excellence (UK) (2015, Feb.). Postnatal care up to 8 weeks after birth. Nice Clinical Guidelines, No. 37. ISBN-13: 978-1-4731-0866-0.
- *Resource refers to birthing person as ‘woman’; MCU supports supporting the personalized gender identity of the birthing personPerinatal Services BC (2016, Oct.) Postpartum and newborn care summary checklist for primary care providers.
How to solve
HLTH 1010: obstetrics/midwifery medical terminology & charting Clinical Contex: Prenatal-Postpartum
Introduction:
As a medical professor responsible for creating college assignments and answers for medical college students, it is important to design tasks that cover a wide range of topics and provide comprehensive information. This particular assignment focuses on the clinical context for midwives, specifically discussing medication records, laboratory services, interprofessional collaboration, and documentation needs. Additionally, it includes the clinical-situational observations and assessments required during the intrapartum phase, the antepartum/prenatal initial visit, the continuing prenatal care, the newborn/neonate examination, and the postnatal/postpartum period.
Answer:
Part 1: Influencing Factors of Content
1. Essential Information on a medication record:
– Prescribed medication details
– Dosage instructions
– Administration route
– Date and time of administration
– Patient’s response or adverse reactions to medication
Factors influencing content:
– Safety considerations
– Legal and ethical guidelines
– Standardized medication administration protocols
– Patient-specific information
– Interprofessional communication
2. Documenting requirements for laboratory services:
– Purpose of the laboratory test
– Specimen collection details
– Laboratory test results
– Clinical interpretation of results
– Follow-up actions or interventions based on results
Factors influencing content:
– Clinical indications for laboratory testing
– Evidence-based guidelines
– Accuracy and reliability of laboratory tests
– Timeliness of documentation
– Communication with laboratory staff
3. Interprofessional Collaboration:
– Interdisciplinary team members involved
– Collaborative decision-making process
– Modifications or updates to the plan of care
– Communication or consultations with other healthcare professionals
Factors influencing content:
– Patient-centered care approach
– Effective communication strategies
– Respect for professional boundaries
– Clear documentation of discussions and agreements
– Adherence to institutional policies
4. Documentation needs to request a consultation and a referral:
– Reason for consultation/referral
– Healthcare professional or specialty required
– Relevant patient information to support consultation/referral
– Documentation of communication and discussed recommendations
Factors influencing content:
– Clinical complexity or uncertainty
– Patient acuity or medical condition
– Availability of specific healthcare professionals or services
– Timely communication and coordination
– Patient preferences and shared decision-making
5. Comprehensive Charting Guidelines:
– Standardized format for documentation
– Clear and concise language
– Sequential and organized presentation of information
– Inclusion of pertinent details, assessments, and interventions
– Compliance with legal and regulatory requirements
Factors influencing content:
– Professional standards and guidelines
– Institutional policies and procedures
– Quality assurance and risk management considerations
– Accessibility and readability of information
– Continuity of care and interdisciplinary communication
