. I'm wondering about the legalities & exposure for an LC if only one of
the dyad is charted on.
Our large HMO has outpatient as well as inpatient lactation services
Inpatient:both mothers and babies are charted on, in their respective
electronic health records.
The first outpatient visit is usually with an LC/RN in the pediatric clinic
with focus on infant wt & jaundice, and lactation issues. There are
follow-up lactation appointments as needed, usually attached to that
service.
Most of our outpatient LC /RNs have been instructed chart routinely only in
the baby's record, not the mother's.
So assessment of breasts, nipples, milk transfer, teachings, interventions,
plans--all of that is only under the infant's medical number. Not seen by
the providers who see mother.
My area clinics may be among the last in our HMO to be made to do this. I
feel strongly that I see a dyad and that on each person-both baby and
mother- the chart should document and communicate, as each person has
different risk factors, histories, lab tests,etc. under different names
(the baby's name/number is not related to the mother's).
Some of it may be due to budget: pediatrics pays for the LC services. Some
of it is time: per management, it should take less time if you only see
"one patient", right?,
I've shown management the IBCLC Competencies that I think support
acknowledging the mother as a patient as well as her child..
Any legal advice out there on the practice of charting only in a baby's
record, especially in an integrated electronic medical record that allows
easy charting in both mother and child, and whose mother undoubtedly
received her ( well-documented) prenatal & other care in the same systerm.
??
Liz Baldwin, do you have any action ideas?
Thanks,
Susan Lawrence, RN, IBCLC, LLLL
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