Different institutions do it differently ... some chart mom, some chart
baby, some have a separate lactation chart that covers both.

The issue needs to be framed in: how do we provide the best service and
care for our patients/cient?  Worrying about the liabilities down the road
short-changes the analysis.  If a mother stands in front of a clinican
complaining of X, Y or Z, surely the clinician would like to know what
advice or assessment has gone on before ... not so as to avoid a lawsuit
two years from now, or to help her collegaues avoid a lawsuit, but to be
able to handle THIS sore weepy scared patient RIGHT NOW.

The decision about the best way to chart is made by the risk managers and
administrative managers at your facility ... but certainly an IBCLC can
offer cogent suggestions and analysis about why it should be done one way
over another.   The discussion is better framed as "How can we provide the
best care, in a timely manner, and have our record-keeping allow other
clinicians to see a record of our care?"

As an FYI -- and for those of us in the USA -- a parallel issue is the
tracking of exclusive breastfeeding rates.  I am typing this while
attending the U. S. Breastfeeding Committee (USBC) meeting, and I am very
excited about an expert panel project coming out of a NICHQ grant to USBC,
to provide recommendations for hospitals to record BFg exclusivity
information on Electronic Health Records (EHR).

With requirements under HIPAA, HITECH, and now the Joint Commission mandate
for exclusive BFg as a perinatal core measure coming Jan 1 2014 (whoo hoo!)
-- institutions are under pressure to figure all of this charting stuff
out, pronto.  This high level, accelerated time frame expert panel hopes to
have implementable software programming and recommendations in 6-9 months.

Right now, every institution does it in a hodge-podge of ways, and is
unwilling (or not asked) to share their systems with other facilities.

Translation:  NO "lone wolf IBCLC" at any facility should be the one person
tracking and measuring exclusive BFg rates!  This is something that should
be tracked on a systems-wide basis.

While that is something of a "side issue" to how *lactation* consults
should be charted (mom, baby, or by themselves?) the exclusive BFg records
analysis may force some big picture thinking, by facilities and healthcare
providers, in how they want to offer and record their lactation care.

-- 
Liz Brooks JD IBCLC FILCA
USLCA Alt Rep and Board Member, USBC, 2012-14
Wyndmoor, PA, USA

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