Clinical Practice Guidelines for Midwifery & Womens Health by Nell Tharpe

By Nell Tharpe

This article provides A Compilation Of present Practices that comes with Evidence-Based, conventional, And Empiric Care From a large choice Of assets. every one guide strikes via challenge identity And therapy utilizing A Standardized layout For day by day medical perform With varied Populations. the tips Are at present In Use through Many Practices As a fashion Of assembly the yank collage Of Nurse Midwives (ACNM) suggestions, And Are appropriate For Collaborative perform With health care professional Colleagues.

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When a consult is obtained the consultant’s opinion must be documented. qxd 11/30/05 10:42 AM Page 19 Documenation as Risk Management consultant’s recommendations for care, and application of those recommendations to the midwifery plan of care. When the consultant evaluates the client in person, the consultant is responsible for documentation of care rendered. Referrals may be made for many types of services, such as counseling, smoking cessation, nutritional evaluation, physical therapy, psychiatric care, substance abuse treatment, alternative therapies, and medical or surgical evaluation of reproductive or other health problems.

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. Well-child exams meet this standard. qxd 24 11/30/05 Chapter 2 Table 2-1 10:42 AM Page 24 Documentation of Midwifery and Women’s Health Care Documentation Recommendations (continued) STANDARD D.

B ■ Avoid in late pregnancy • Muscle spasm (Murphy, 2004) • Flexeril ■ 10 mg tid ■ Pregnancy Cat.

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