By Nell Tharpe
This article provides A Compilation Of present Practices that comes with Evidence-Based, conventional, And Empiric Care From a wide selection Of assets. every one guide strikes via challenge identity And therapy utilizing A Standardized layout For day by day medical perform With diversified Populations. the information Are at the moment In Use by way of Many Practices As a manner Of assembly the yankee university Of Nurse Midwives (ACNM) concepts, And Are appropriate For Collaborative perform With medical professional Colleagues.
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Extra resources for Clinical Practice Guidelines for Midwifery & Womens Health 2006-2009
When prior records are unavailable, practitioners may document that a child’s parent or guardian affirmed that immunizations were administered by another practitioner and the approximate age or date the immunizations were given. 22. Requests for consultation are consistent with clinical assessment/physical findings. • The clinical assessment supports the decision for a referral. • Referrals are provided in a timely manner according to the severity of the patient’s condition. • Referral requests and expectations are clearly documented.
Thorough documentation using a standardized format allows objective evaluation of the care provided. Each note should be written from the objective, outside observer point of view. qxd 20 11/30/05 Chapter 2 10:42 AM Page 20 Documentation of Midwifery and Women’s Health Care poor notes are better than no notes, thorough documentation is the ideal to strive for. Use of fill-in-theblank forms can be a useful way to quickly record essential information, especially during busy office hours or in an emergency.
Clients must know what is expected of them in order to comply with recommendations for care. Follow-up may include returning for a scheduled visit, such as a prenatal visit, or it may be that the midwife is going to contact the client following test results, such as after a mammogram performed on a client with a suspicious breast mass. When there is any deviation from normal or expected findings, a clear plan for follow-up should be documented. In the example above of a woman Collaborative Practice: Consider Consultation or Referral Every request for consultation or referral should be clearly documented.
Clinical Practice Guidelines for Midwifery & Womens Health 2006-2009 by Nell Tharpe