I keep phone logs on the back page of my mom's assessment page. If it is a
mom who did not deliver here, I make a page for her.
We keep these records for 1 yr. That is what legal recommended. We then
shred them.
I do not necessarily write 'exactly' what I told the mom.
I might write
reason for contact: call in for engorgement
"engorgement measures discussed incl. cold, cabbage, expression. s/s
mastitis to monitor for and report to MD discussed. Mom instr to call back
if measures not providing relief in 24 hrs."
I would not write "use cold compresses x 20 min.... or "express breasts for
20 min every 2 hrs" becoz that is just too specific and time consuming for
me.
I might get a call about going back to work, intro of bottles - I would
write reason for contact: ret. to work
"strategies and anticipatory guidance for return to work and intro of
bottles, maintaining supply, and maintaining bf discussed"
I would not write every little detail down.
You get the idea. I still think this would stand up in court, with my
credentials and experience.
Laurie Wheeler RN MN IBCLC
Mississippi USA

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