Hi Jennifer,

I think the SOP will never be perfect.  I also think that, probably, it is
geared more toward the hospital-based LC and PPLC who works closely with
other hcps in an institutionalized health care system. The reason being, the
majority of IBCLCs fit in these categories. Nothing against those who don't.

I'm not sure of your situation, but it would be prudent to keep records of
your encounters with clients, your assessments, and recommendations, and
followup, which I'm sure you already do. At my hospital, I have been asked
to keep my records for 1 yr, which I do, and then shred the documents. They
are not part of the permanent medical record, altho I do chart on the mom's
and baby's chart. But I have my own form that is more detailed, and allows
the next LC (I work part time) to follow behind me pretty easily. It also
has when the f/u appt is or when a phone call is scheduled, what devices
they are using, if any, and if they participate in WIC and what county.

Anyway, back to the SOP. In your case, do you work with a certain number of
hcps like midwives, chiropractors, DOs etc? You could ask each one what kind
of reporting they would like. For example, if there is an easy fix, like a
latch situation, you could have a very simple pre-printed postcard,
something like "saw Ms X for basic bf help on 4/9/08" and your contact info.
If there is a problem, you could just as easily call the hcp directly, make
the referral, say for TT, and just record in your records. That consitutes
reporting. You could also send a more formal report, or just a form with a
checklist, like doctors use with medical diagnosis codes (you don't
necessarily need to include the codes). As you know, there are many examples
of forms in LC texts. If the folks you work with have faxes or emails, you
could send a brief report that way. I inform the families that a report will
be made. I actually have a nice f/u appt sheet which tells them about the
report and that either mom or baby doctor will be informed of any problem.

If you have a client who is not involved with any other hcp, and you are the
only one, and there is no health risk, but only a quickie latch fix, for
example, then I would keep the record and note there was no hcp indicated.
If the client has a real problem, and does not have an hcp indicated, then
hopefully she will allow you to make a referral, say for an abscess or
something, and then that referral hcp is the one you would report to
verbally or written, and you would record in your notes, of course.
Hope I am making some sense and you find some of this helpful.
Laurie

Laurie Wheeler RN MN IBCLC
Mississippi USA

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