I'm with Barb W-C. I started out as an independent LC in the field, and I'm
using the same format for my notes today (with lots more initials after my
name) as I did then. Now as a hospital based LC, I use a "progress note"
page, and my categories are:
Mom - (subjective and objective info, with bullets)
Baby - objective info and what mom tells me, in quotes
Feed - What I observe
Teaching - What we did or said
Assessment - (usually a nursing diagnosis - "potential for effective
breastfeeding" or "Knowledge deficit" or "Alteration in tissue
integrity.....)
Plan --

I still meet HCP office staff who say, "I love reading your notes, I learn
so much."
 HIPAA has nothing to do with this as long as you have mom's permission to
share. Mom of course signs a consent for me to work with her. Somewhere
along the line I say, "And I'll share this with (your dr) (your baby's dr)"
-- moms are usually relieved that they won't have to explain it all to
someone else.
And it's been a great tool for collaboratively helping moms and babies.

Dawn Kersula in Brattleboro VT (where we did a QI project asking moms what
was the greatest help to keep them breastfeeding -- thank heavens the answer
was The LC in the hospital!!)

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