# Situation: A nurse is the charge nurse of the 30-bed postpartum ward of a government hospital. Each shift is staffed by registered nurses and nursing attendants. At 0815H, a staff nurse writes a note about a mother she assessed at 0800H, 12 hours after vaginal birth. Which entry is documented BEST?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse is the charge nurse of the 30-bed postpartum ward of a government hospital. Each shift is staffed by registered nurses and nursing attendants.

At 0815H, a staff nurse writes a note about a mother she assessed at 0800H, 12 hours after vaginal birth. Which entry is documented BEST?

## 보기

1. 0800H Fundus firm, at the umbilicus; lochia rubra, moderate; 0900H ferrous sulfate 1 tablet given by mouth.
2. 0800H Fundus firm, at the umbilicus; lochia rubra, moderate, no clots; states 'my stitches sting,' pain 4/10. **✔ 정답**
3. 0800H Fundus firm, midline; lochia rubra, moderate; mother uncooperative about walking and refuses to try; physician informed.
4. 0800H Fundus firm. Lochia normal. Perineum healing well. States she is fine. Mother resting comfortably and doing well.

**정답: 2**

## 해설

Good documentation is factual, objective, complete, and never written before care is given. The best entry records measurable findings and the mother's own words with a pain score. Vague terms such as 'normal' or 'doing well', labels such as 'uncooperative' without the behavior described, and entries for care not yet given all weaken the record.

## 심화 해설

Why Option 2 Is the Best Documentation

The strongest nursing note records what was actually observed and measured at the time of assessment, includes the patient’s own words, and adds an objective pain rating. Option 2 does all of this: it states the fundus is firm and at the umbilicus, describes lochia rubra as moderate with no clots, and then quotes the mother’s report of perineal pain with a numeric score of 4/10. Documentation is most defensible when it combines objective physical findings with subjective patient statements and a quantifiable pain scale.

In the postpartum setting, this level of detail matters because the first 24 hours after birth carry the highest risk for primary postpartum hemorrhage. The reference project by Ogawa et al. emphasizes that standardized, formal documentation of early bleeding signs is a key strategy for early recognition and prevention of maternal morbidity from hemorrhage [1]. A note that says only “lochia normal” or “doing well” does not give the next nurse a usable baseline for detecting a change in bleeding or uterine tone.

What Weakens the Other Options

| Option | Documentation Problem | Clinical Concern |
| --- | --- | --- |
| 1 | Records ferrous sulfate at 0900H even though the note is written at 0815H | Watch out! Charting care before it is given is inaccurate and legally unsafe; the entry is not a factual record of completed care. |
| 3 | Uses the label “uncooperative” without describing the specific behavior; also charts “physician informed” without noting the time or response | Watch out! Labels are subjective and judgmental. Documentation should describe what the patient said or did, not interpret it. |
| 4 | Uses vague terms: “normal,” “healing well,” “fine,” “doing well” | Watch out! These words are not measurable and do not allow another clinician to detect deterioration from baseline. |

Applying This to Postpartum Hemorrhage Surveillance

The first 24 hours after vaginal birth are the highest-risk window for primary postpartum hemorrhage. The implementation project from São Paulo highlights that formal documentation of increased bleeding is a best-practice strategy because it supports early diagnosis and timely intervention [1]. A note that records fundal height, firmness, lochia amount and character, and pain level gives the care team a precise baseline. If the next assessment shows the fundus has risen above the umbilicus, lochia has become heavy with clots, or pain has escalated, the change is immediately recognizable.

The best documentation is factual, objective, complete, and written only after care or assessment has actually occurred. Option 2 meets these criteria by pairing measurable physical findings with the patient’s own words and a numeric pain score, which is exactly the kind of record that supports safe postpartum monitoring and clear communication across shifts.References (research sources)

- [1]Prevention and management of primary postpartum hemorrhage among puerperae in a teaching hospital in São Paulo, Brazil: a best practice implementation project.Research articleOgawa L, Shimoda GT, Wei CY, Püschel VAA (2019) · DOI: 10.11124/JBISRIR-2017-003830

## 임상 시나리오

Postpartum Documentation EssentialsCharting objective findings and patient reports accurately
The strongest note combines objective physical findings with the patient's own words and a numeric pain score. Example: fundus firm at umbilicus, lochia rubra moderate without clots, and pain rated 4/10.

Avoid vague terms like normal or doing well. These do not give the next nurse a usable baseline for detecting changes in uterine tone or bleeding during the first 24 hours when postpartum hemorrhage risk is highest.

CautionNever chart care before it is given. Recording a medication at 0900H when the note is written at 0815H is legally unsafe and not a factual record of completed care.

## 핵심 개념

- **Objective documentation** — Recording measurable, observable findings such as fundal firmness, location, and lochia amount rather than subjective impressions.
- **Pain scale** — A numeric rating, such as 4/10, used to quantify the patient's subjective pain report for consistent reassessment.
- **Lochia rubra** — The normal red vaginal discharge during the first few days postpartum, consisting of blood and decidual debris.
- **Fundal assessment** — Evaluation of uterine firmness and position after birth to detect atony, a major cause of postpartum hemorrhage.
- **Factual charting** — Documenting only care that has already been performed and observations actually made, never future or anticipated actions.

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