Foundations for Charting & Coding - Session 6

Labor & Delivery Documentation

Your care tells a story. Does your documentation capture the full picture?

Labor and birth can involve hours of assessment, hands-on care, clinical decisions, and changing plans. How do you make that work visible in the record – and document it with the clarity needed to support the services you provide?

Join us for a practical deep dive into charting with a procedure mindset. We’ll explore how to move beyond a familiar labor narrative to clearly document what happened, when it happened, who provided the care, and why it mattered.

Using fictitious birth center delivery and intrapartum transfer records, we’ll work through real-world documentation challenges, including:

• Mapping the intrapartum timeline: Connecting assessments, decisions, interventions, reassessments, and outcomes.

• Making your work visible: Capturing provider attendance, labor management, and the clinical reasoning behind your care.

• Documenting a transfer: Telling a clear story of the decision to transfer, care provided before departure, and the handoff.

• Thinking like a proceduralist: Applying the documentation habits used for other procedures to labor and delivery.

• Looking ahead to 2027: Introducing upcoming maternity coding changes and discussing unresolved questions – including labor that crosses midnight – without treating assumptions as established billing rules.

Whether you provide care, review charts, or support billing, you’ll leave with a clearer framework for documenting the skill, time, and decision-making involved in labor and delivery.

Bring your questions and join us live for a closer look at documentation that reflects the care you actually provide.

Join experienced billers Nancy Koerber and Marnie Cabezas every other Friday as they guide you through the mechanics of modern documentation and billing. This series is designed to establish a rock-solid foundation for your practice’s long-term financial health.

For access to previously recorded sessions and full details on the series, visit: 

Foundations for Charting and Coding

Presenters