Hi Anne ... I've found it works best to keep my in-patient  charting
concise and brief.  No one seems to read it, but I know it's there for
me to reflect on, if needed at a later time.

At this point, I document as clearly as I can on outpatient referrals
and send a copy of the documentation to the referring HCP.  Calls
between the Mom and me are usually "non-medical in nature" and would
involve volumes if I were to formally document.  So I keep a notebook of
calls for  my own reference.  Just MHO......

Susan Wirtjes RN IBCLC
hospital LC in Waterloo, IA
retired LLL Leader
Mother of Sean,28
Jill,26 and Ryan, 22 years (back in the days when breastfeeding was
really considered weird!!!)

from Susan in Iowa (is this heaven?)

"What you permit, you promote"