I was instructed to write separate reports in the Progress Notes section for each chart. That's very time consuming, but necessary because I'm working with two people. It's difficult when so many consult requests are for RIGHT NOW!!
We have not achieved electronic charting yet, but it's coming soon. I provided a blank copy of a separate LC report form. Have no idea how the committee is adapting it to electronic use.
Phyllis

---- Pat Young <[log in to unmask]> wrote: 

=============
This was my question and I received 17 answers - all different!

where do you write notes as IBCLC at your hospital?

A. In nurse's notes for mom in mom's pemanent chart
B. in nurses's notes for baby in baby's permanent chart
C. on a special lactation sheet in baby's permanent chart
D. on a special lactation shee in mom's permanent chart
E. Other - please explain where.

Results

Electronic records 
2 write in baby's chart and copy/paste into mom's
3 write in mom's chart and copy/paste into baby's
1 writes in each

Paper
1 mom & baby
1 mom's chart, phys note page, then reports to RN who writes in         baby's chart
2 Special Lactation sheet
1 baby's chart in nurses notes, occassionally in mom's chart if baby     is in NICU

Variations
Assessment sheet, kept by LCs for one year, not part of medical         record.
Lact. Initiation Assessment - mom's chart
BF Score & problem sheet (Excell or Excellian)
LC Charting section on baby's chart for LC, BF score sheet on            baby's chart for nursing
2 Lactation form in mom's permanent chart

Such variation - and as we all go electronic in US, it will be interesting.

Legally I think LCs need to write in each chart, whether it may be copy/paste system or separate notes.  But I'm not a lawyer or a hospital legal advisory team :-)  I'd love more input on this.  Thanks, Pat in SNJ


   --
Phyllis Adamson, BA, IBCLC
Glendale, AZ.
[log in to unmask]

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