This is a dilemma as it does take time to chart, and especially if either
one of the dyad are having trouble.
At my facility, we have a teaching/education sheet for the mother. One of
the teaching categories is breastfeeding, so we just fill that in with codes
for demonstration, verbal info, written info, etc. I write in next to the
word "breastfeeding" things like "and pump use" or "a premature infant"
because that is explains that I taught further than just normal bf stuff. I
would also write in "use of lactation aid" etc.
Now, for the baby, I chart on the progress notes, so it gives more detail if
there is a problem. I do wish there was a way for normal/no problem dyads to
have a quick check off that certain teaching/assistance was done. But if we
are charting on the medical record, unfortunately there are 2 separate
beings that something needs to be said about. If baby comes back in hospital
days later, if makes no sense to pull the mother's chart to see what was
going on with him. However, the mother's body and confidence and competence
do affect baby so I would definitely be charting on the baby's record how
the baby is doing and (if relevant) something about mother e.g. inverted
nipples or
hx of PCOS and insufficient milk, will follow closely etc.
Not sure how we could do this with just one chart. However, I do have my
lactation form, which is mom/baby together but it's not part of the medical
record, it's kept on file and I shred after 1 year.
Laurie Wheeler RN MN IBCLC
Mississippi USA

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