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Lactation Information and Discussion

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Subject:
From:
Mary-Jane Sackett <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Fri, 12 Nov 2010 20:50:09 EST
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text/plain
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For documentation of my consults, I write a progress note on the infant's  
record, control C it to copy and after saving it, I then open up the 
mother's  medical record and paste the note in the progress notes in the  mother's 
chart. I change "Pt's mother" to just "Pt",.so it reflects that I am  now 
documenting teaching and assessing  this patient (the  mother.) I figure I am 
working with two patients with two records so what I  did, saw, how I 
assisted and educated needs to be in both charts. Mother will  have a "breast 
assessment" intervention and infant will have an "intake and  output"  
intervention that is filled out when I observe a feeding.
 
Hope this helps. Our EMR (Electronic Medical Record) uses Meditech,  and 
documenting this way saves me a lot of time. 
 
Mary-Jane Sackett, RN, IBCLC, RLC
Pittsfield, MA (in the beautiful Berkshire Hills of  Massachusetts)

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