You are right on all counts. They are individuals with separate charts. BrFdg is not just a mother issue. The clinic Pedi needs to know about baby feeding issues. Our Scope & Stds of Practice require charting on BOTH patients.
Phyllis Adamson IBCLC
Susan Lawrence <[log in to unmask]> wrote:
>. I'm wondering about the legalities & exposure for an LC if only one
>of
>the dyad is charted on.
>Our large HMO has outpatient as well as inpatient lactation services
> Inpatient:both mothers and babies are charted on, in their respective
>electronic health records.
>The first outpatient visit is usually with an LC/RN in the pediatric
>clinic
>with focus on infant wt & jaundice, and lactation issues. There are
>follow-up lactation appointments as needed, usually attached to that
>service.
>Most of our outpatient LC /RNs have been instructed chart routinely
>only in
>the baby's record, not the mother's.
>So assessment of breasts, nipples, milk transfer, teachings,
>interventions,
>plans--all of that is only under the infant's medical number. Not seen
>by
>the providers who see mother.
>My area clinics may be among the last in our HMO to be made to do
>this. I
>feel strongly that I see a dyad and that on each person-both baby and
>mother- the chart should document and communicate, as each person has
>different risk factors, histories, lab tests,etc. under different names
>(the baby's name/number is not related to the mother's).
>Some of it may be due to budget: pediatrics pays for the LC services.
>Some
>of it is time: per management, it should take less time if you only
>see
>"one patient", right?,
>I've shown management the IBCLC Competencies that I think support
>acknowledging the mother as a patient as well as her child..
>
>Any legal advice out there on the practice of charting only in a baby's
>record, especially in an integrated electronic medical record that
>allows
>easy charting in both mother and child, and whose mother undoubtedly
>received her ( well-documented) prenatal & other care in the same
>systerm.
>??
>Liz Baldwin, do you have any action ideas?
>
>Thanks,
>Susan Lawrence, RN, IBCLC, LLLL
>
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