<< I have a question regarding charting forms. I currently chart in paragraph
 form, keeping patient records on my computer (initial reports), and then I
 chart by hand (*ok, so I'm an older nurse who used to chart by hand and
 still does*)... : ) >>

Dear Kathleen,

Guess I'm an old nurse, too, probably, even older because I type my initial
reports on the computer but print to mail to drs and client and keep a copy
for myself (can't get myself not to have written records).  I tend to write a
detailed report like I used to with patient charting in my hospital days,
several paragraphs with SOAP type recording but narrative form.  (SOAP stands
for type of info: S-subjective, O-objective, A -assessment and P-plan of care
or approach.  I've had other LC's ask why I chart such lengthy and detailed
reports.  Well, I've received feedback( via grapevine usually) that Peds
learn from what I write and one even shared it with an office nurse, saying"
read this, you'll really learn alot," moms learn from it and I have a
thorough jog for my memory (which fails me frequently!).

I've learned to use non diagnostic statements and the client stated (using
the mom's name) sentences and what I responded to the mom in way of teaching
or instructing and why.  I find this just staes the facts and I'm not
stepping on toes or critisizing another's judgments or approach.  Lastly, I
love to write so though it's time consuming, it sounds and looks great and
professional when I'm done.  (I'd rather at times be writing articles or
essays, but that's another story...)

I've no answer re superbills, I use the usual diagnostic code on a bill I've
had made up and ask docs to write a note and co-sign to aid reimbursement;
only works with insurance co once in awhile.  I also give 2 one page
statements about money savings with BFing for parents to send in with my bill.

Hope this answers some of your question.

Barbara Latterner, BSN, RN, IBCLC
Brewster, NY

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