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Fri, 12 Nov 2010 20:50:09 EST |
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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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