By Nell Tharpe
This article provides A Compilation Of present Practices that incorporates Evidence-Based, conventional, And Empiric Care From a wide selection Of resources. every one instruction strikes via challenge id And therapy utilizing A Standardized layout For day by day medical perform With varied Populations. the tips Are at the moment In Use through Many Practices As a manner Of assembly the yank collage Of Nurse Midwives (ACNM) options, And Are applicable For Collaborative perform With general practitioner Colleagues.
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Additional resources for Clinical Practice Guidelines for Midwifery & Womens Health 2006-2009
Many midwives who practice in the out-of-hospital setting opt to use the informed consent process to present information on birth center or home birth. This provides opportunity for questions, discussion, and documentation of client participation in decisions. • Objective: Physical exam and testing • Assessment: Differential diagnosis • Plan: Evaluation, treatment, education, and follow-up care including coordination of care, consultations, and/or referrals In most cases, it is clear whether or not the client is competent to make her own decisions.
Past medical history is documented and includes serious accidents, operations, and illnesses. C. Family history is documented. • A. Initial history and physical examination for new clients is recorded within 12 months of the first visit or within three visits, whichever occurs first. If applicable, there is written evidence that the practitioner advised client to return for a physical examination. The record of a complete history and physical, included in the medical chart and done within the past 12 months by another practitioner is acceptable.
When off-label medication use is prescribed, it should be documented as such, and should include documentation of relevant discussions with the client regarding clinician recommendations for off-label medication use and informed consent for such use. Other treatments, such as physical therapy or respiratory therapy treatments, should be documented as ordered, including the indication for the treatment. ” Providing Support: Education and Support Measures to Consider Client education is an integral part of most midwifery practices and as such should be clearly documented.