ATTENTION FIRST YEAR STUDENT MIDWIVES… Your PAD, White book and signatures!

I APOLOGISE AS THIS IS LONG…STICK WITH IT….. IT’S IMPORTANT INFORMATION;-)

Ok…you first years are all starting to think about placement right? It’s about a month away for the student midwives so your uniforms will be arriving shortly if you don’t already have them and you will have your documentation staring out of wherever you have hidden it because, if you’re anything like me, the thought of even starting to read that huge PAD document thing on top of all the studying you have to do is so out of the question it’s unbelievable!

Well I am here to hopefully hold your virtual hand through the whole documentation experience and share my many mistakes so you don’t make them!

First of all let’s clarify the difference between your

pad

 

PAD (Practice Assessment Document)……

 

 

 

 

white-book

 

 

……..and your white book (Record of Statutory Clinical Midwifery Experience).

 

 

 

 

 

You may not believe this but it took me a good couple of months to work out who can sign what and how equally important but different these two documents are!

 

So I’ll start with what I think is the easier one-the White Book. This will be held by you for the full 3 years then handed in at the end of your degree. Your AA will look through this during your individual meetings just to make sure you are ‘on track’.

The White book is where you record your statutory skills which every student midwife at every university will have to get signed off before they can qualify. You have the space in here to log your 40 births which seems to be the area of focus for a lot of students but there are A LOT more skills you need to achieve as well as delivering babies. For example, you need to record evidence of  antenatal examinations & care of 100 pregnant women and examinations & care of 100 postnatal women and their newborn babies.

In these midwifery areas any qualified midwife can sign off your evidence. They DO NOT need to be a mentor/sign off mentor. This is important because you will work with a lot of midwives when on placement and you may carry out a beautiful abdominal palpation and listen to the fetal heartbeat with a pinard whilst your mentor is on a break and you are working with another midwife…..WRITE IT IN YOUR WHITE BOOK AND GET IT SIGNED OFF! The white book just needs the woman’s hospital number, the date, what you did and the midwife’s signature. It can be written up in a couple of minutes and signed there and then! Otherwise you will get home, not written down half the hospital numbers for the women you have worked with that day, for the ones you have written down you’ll have forgotten what parity the woman was or the pregnancy gestation and for the ones you can remember you will realize the midwife who you worked with is now on maternity leave and so won’t be around to sign that evidence off (YES…ALL these have happened to me!!!-it’s gutting!).

There’s areas of the white book which can be signed off by qualified Healthcare professionals who work in other areas i.e. neonatal staff  or breastfeeding support  workers but the important thing to get into your heads about the white book is…

ANY QUALIFIED HEALTHCARE PROFESSIONAL CAN SIGN YOUR EVIDENCE FOR THE RELEVANT AREA YOU WERE IN WHEN YOU COMPLETED THE SKILL

AND

GET IT SIGNED THERE & THEN!

 

OKAY…..big, deep, breath…..THE PAD! Unlike the white book your PAD skills and interviews get handed in at the end of each academic year but you keep the folder (mine is already wrecked!). Your PAD skills are handed in through an official process where you are given a deadline (date & time) and you complete a front sheet for each set of skills and hand them into an exams officer (I point this out because this process was much more official than I expected it to be and it unnerved me a bit!). Your AA will probably take your interviews but this does depend  on the AA; I still have my complete set of first year interviews but I know a lot of my cohort have handed theirs in.

Signing stuff- this is a bit trickier than the white book as the people who can sign your skills off are limited. Let’s just talk about the actual documentation as an opener……..

Interviews

Ideally, at the start, mid point and end of each placement you and your mentor need to sit down and do your interviews. These will be read and checked at your AA meetings and are important for all parties involved as they help you assess where you are up to and also help you gather your thoughts on whether you are getting what you need out of the placement and if not how you can be proactive in accessing more opportunities.

During your mid placement interview do not forget to get your mentor to sign the actual interview AND the mid placement interview section on the front sheet of the set of skills you are working on (i.e. in the community this may be ‘Midwifery Care Pregnancy & birth antenatal skills’ section of your PAD. If your mentor has students from different universities they may not be familiar with UoM paperwork as every uni is different so its your responsibility to ensure every thing is completed.

As an aside, I did not realize our skills directly related to the academic units we were doing until about 6 months in…..don’t judge me I was overwhelmed!!!

Also you will have your progression points at week 19 & week 52….these tend to coincide with final placement interviews but not always so stay on top of these dates….get them in your diaries as both your mentor and AA need to write comments and sign these.

Skills

The skills section of your PAD is divided into 4 sections. Familiarise yourself with the sections, notice which sections coincide with your academic units so you can use what you are learning in university to inform your practice and vice versa, then write them up! Sounds obvious but it isn’t always! For example, if you have been learning about abdominal palpation in university and you are out on practice in the community, tell your mentor you have had a session on abdominal palpation and the use of pinards. Let your mentor know that you would really like to practice this in clinical placement. Your mentor will support you in this (if the opportunity arises) then you can write this skill up using all the theoretical knowledge and the practical skills you gained then get your mentor to sign this skill off! This, I recognise, is an ideal world scenario but this is YOUR clinical placement….make it work for you. This is your opportunity to apply what you are learning in theory to your practice; it is NOT your mentors responsibility to work out which skills you need to practice and get signed off!

Mentor/sign off mentor/SIGNATURES

You will be assigned a mentor when you go on placement for every clinical area you will be working in. You need to find out if they are a sign off mentor (they are usually quite forthcoming with this information!). Only sign off mentors can sign your paperwork and assign you a grade. If your mentor is not a sign off mentor ensure you know who the sign off mentors are in that clinical area and try and work at least a couple of shifts with them. Your mentor can sign your skills but the sign off  mentor needs to countersign them. THIS IS NOT THE SAME AS YOUR WHITE BOOK ! So if your mentor signs off that you are amazing at communicating with women the sign off mentor needs to countersign and date this skill as well.

I am going to **star** and bold and italic this next sentence because this caught me out on my placement and meant I spent most of my last shift at my first year trust running around trying to find one member of staff and ringing my AA almost in tears……..

******AS SOON AS ANYONE SIGNS YOUR SKILLS IN YOUR PAD MAKE SURE THEY SIGN THE SAMPLE SIGNATURE SHEET FOR EACH SET OF SKILLS THEY HAVE SIGNED AND WRITES DOWN WHEN THEY LAST HAD A MENTOR UPDATE******

(i.e. if a sign off mentor countersigns a skill in the ‘intrapartum care’ section of your PAD and the ‘tackling health inequalities’ section of your PAD, THEY NEED TO SIGN THE SAMPLE SIGNATURE FOR EACH SET OF SKILLS.

Imagine the scenario….you are finishing a night shift on the midwifery-led birth centre and the midwife you worked with observed you support a couple during a lovely labour & delivery. You had the opportunity to write up the skills you demonstrated during this shift and you got your midwife mentor to sign these skills off and she quickly got the sign off mentor, who’d just come on an early shift to countersign them before both you and your mentor floated off home to sleep…… WITHOUT GETTING THE SAMPLE SIGNATURE SHEET SIGNED BY THE SIGN OFF MENTOR!!! YOU NEED TO GET THE SAMPLE SIGNATURE SHEET SIGNED (yes this is what happened to me!!!) If you don’t, as a first year your PAD will be referred and you will have to return to your old trust to track down the sign off mentor to sign the sample signature sheet and then resubmit the whole skill set. If you do not have all the signatures completed on the sample signature sheet in second and third year YOU WILL FAIL (this makes me feel sick!).

Another starred, bold, italic section coming up……………………….

****YOU NEED TO DATE EVERYTHING YOU SIGN****

A LOT of my cohort got our PAD skills returned to us because we hadn’t dated our signatures on our skills documents! We had ensured our mentors had dated everything but we actually hadn’t! There is no ‘date’ prompt next to the student signature section but you do need to date it! I cannot begin to tell you what a complete pain in the rear it is when you have finally tracked down the sign off mentor to sign your sample signature sheet, hobbled, exhausted and emotional to hand in the PAD documentation hoping you never have to see it again, only to get it ALL handed back as ALL my signatures needed dating! Literally, every single one of the 60 or so skills I needed to go through and date! DATE THEM!!! Believe me you will not want that PAD handed back to you! If you aren’t sure if something needs dating and signing do it anyway! I am very much ‘better to be safe than sorry’ …once bitten and all that!!!

Think that’s all the terrible tales I need to pass on about documentation!! I do wonder how I managed to even get on this degree as reading back over this makes me look a bit lacking but I blame sleep deprivation!

You will be getting your uniforms soon-empty all pockets before you take it off and buy a tub of vanish….white is a TERRIBLE colour! What were they thinking giving nervous, tired students white?!! One night shift my pen had leaked in my pocket and because I was on an antenatal ward and the women were sleeping, all the lights were dimmed ….by the time I realised my pen had leaked I had fingerprints on my uniform, on some lovely white sheets, on a couple of CTG monitors and on my face!

uniform I was very glad I had purchased a tub of vanish big enough to bath a baby in!

Good luck and DATE EVERYTHING!!!!

 

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Writing in Patient Notes

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Documenting patient care can be a daunting task.

  • What did I do today?
  • Do I really need to write all of this down?
  • Is what I’m writing making any sense to someone else reading it?
  • Have I kept any personal judgements out of the notes? (e.g. patient is friendly)
  • Did I use ambiguous terms like ‘ok’, ‘good/bad’, ‘high/low’ without giving more specific information? (e.g. ‘pulse low’ versus ‘pulse low (39)’)
  • What are the things that other members of the Multidisciplinary Team (MDT) need to know about the care I gave my patient today? (e.g. how much is too much information?)

Document as you go along or in one large paragraph at the end of the shift

It is considered good practice to write about care as it happens so that you are less likely to forget or incorrectly document any care that has been provided. In practice, however, you may find it difficult to set aside time to write in bits and pieces throughout the day. Most nurses tend to record important clinical decisions, test results, scores etc. on their handover sheet as they go and then document it all in one sitting later on in the shift. You will gradually find what you are comfortable with and what works for you on your ward. Just remember that documenting care accurately is very important. You will often hear staff say that documentation is your safeguard against lawsuits or the NMC questioning your practice. I prefer to consider the patient’s situation first and say that accurate documentation benefits your patient immensely by keeping them safe. If the rest of the team is up-to-date with what care the patient has already received, what stage they are at with mobility, continence, wounds etc. then other staff will be better equipped to plan their own further interventions.

Different types of documentation systems

You’ll see lots of different systems for documenting patient care. Every ward/district/trust does it slightly differently.

Among the possibilities you will see are:

  • preprinted care plans that just require a signature and may have a free text set of blank lines on the back to note anything out of the ordinary,
  • reams of blank line sheets just on their own – usually called ‘continuation sheets‘ – where all the care is documented in paragraph style,
  • separate styles of continuation sheets for nurses and medical staff where doctors, physiotherapists (physios), occupational therapists (OTs), etc. will document their patient visits on one type of sheet with blank lines and nurses will use another slightly different type with blank lines,
  • places where all staff write on the same sheet with blank lines and nurse, doctor and OT notes will all be mixed up together with or without preprinted care plans.

Writing in preprinted care plans can seem easier as there is a defined structure that prompts you to provide the pertinent information. It can also be frustrating when you have something to add that doesn’t quite fit in any of the care plans as they are often rather specific. Some nurses will tell you that they ignore the small areas for free text on the preprinted care plans and simply rewrite everything in a main continuation sheet of nursing notes. Again, you will find what works best for you and your workplace. There are arguments for and against any method as well as arguments for and against an NHS wide standardisation and a ward specific way of documenting. This is ongoing and you’re likely to see as much change in your job once qualified as you have done during your training!

Keeping it accurate, concise and comprehensive but relevant

Easier said than done, right? You know what you have accomplished on the shift, but to condense everything down into a smallish paragraph can be tricky. It is definitely a good idea to start getting a pattern to what you write which will help you avoid missing out any care given. I have seen people who write chronologically, some who write according to body systems (e.g. anything to do with respiratory first, then anything to do with cardiovascular, then renal etc.) and those who have their own set pattern.

Documentation Example

This is an example of how you might consider setting out your notes. It would be written in paragraph form, not bullet points as gaps should not be left on lines to prevent additions to your writing after you have signed it. You will find this is something nurses stick to but medical staff do not.

  • Written retrospectively
  • Patient care taken over at 07:30.
  • Initial observations completed, EWS = 1 due to low systolic (93/51). Monitored over next hour and currently EWS=0.
  • Patient reports no pain/nausea.
  • No shortness of breath. SpO2 and respiratory rate within range. Patient on nasal spec (2L O2).
  • Patient required some assistance x1 with wash this morning.
  • All pressure areas intact, SKIN Bundle completed.
  • Passing urine but bowels not opened as of 13:30.
  • Diet and fluids taken.
  • Anti-hypertensives and diuretic withheld due to low systolic, all other medications administered as prescribed. Patient encouraged to drink fluids. Medical staff informed.
  • Patient mobilising independently with frame – advised to request support if required.
  • TED stocking (large) removed and reapplied after 30 minute rest.
  • Surgical wound (right knee) dressing dry and intact. No signs of inflammation/infection.
  • Recent test results: Hb 132, Urine dip = NAD, MRSA negative
  • Section 2 sent
  • All care explained, patient fully capable of expressing needs.
  • Water and call button in reach.
  • Patient reports comfortable, no concerns at present.

The majority of this is pertinent to most patients. Some will be shorter if, for example, their EWS=0 you would just put ‘Initial observations completed, EWS=0.’ Or if they were on room air instead of nasal cannulae you could say ‘No shortness of breath. SpO2 and respiratory rate within range on room air.’ It is difficult to avoid repeating documentation, for example, I have not included VIP scores for a cannula as this more than likely will have its own separate sheet. Feel free to include it yourself. You will also no doubt think of something else I could have included and this is the nature of documentation. I guarantee you that as soon as you write the final line and sign your name you’ll remember something else to include and end up adding one more line at the end and signing all over again.

What is important?

Well everything and nothing really. Different healthcare professionals will tell you that they only want to hear about x, y, and z when others want a, b, and c. The best you can do is present the information in an organised fashion that clearly and concisely states the contact you have had with your patient. The information should also help staff to notice developing patterns. For example, if a patient has not opened their bowels for a few days and you notice this reading through the last entry, you may wish to discuss this with the medical team to see if an appropriate laxative can be prescribed. Or if a patient continually reports severe pain first thing in the morning, understanding why this is the case and discussing possible changes to their available breakthrough analgesia would benefit the patient greatly.

Remember this is a learning process and no one size fits all. Keep the safety and quality of your patient’s care at the forefront of your mind at all times and you will be fine.