Private Practice

Mastering the Art of Note-Taking: Essential Tips for Lactation Consultants During Visits

October 31, 2023
Mastering the Art of Note-Taking: Essential Tips for Lactation Consultants During Visits
← Back to Blog

Note Taking at Lactation Visits

Effective note-taking is not just a skill, but an essential tool in enhancing the quality of care you provide. As a new lactation consultant, it can be challenging to know exactly what to capture. You want to be sure to capture all of the relevant details without getting bogged down with too much extra.

This post is designed to guide you through the art of note-taking during lactation visits. We'll explore strategies to capture key information efficiently and accurately, ensuring that your records are both comprehensive and useful. Whether you're a seasoned LC or just starting out, mastering the art of note-taking will empower you to provide more personalized, effective guidance to the families you support, and ultimately, contribute to the success of their breastfeeding journey.

[pac_divi_table_of_contents title="Outline" allow_collapse_minimize="off" level_markers_1="icons" icon_marker_1="E||divi||400" level_markers_2="icons" icon_marker_2="C||divi||400" title_container_bg_color="gcid-02132a14-0aa3-45af-abdc-389c29b58c23" _builder_version="4.19.5" _module_preset="default" title_text_color="#474747" global_colors_info="{%22gcid-02132a14-0aa3-45af-abdc-389c29b58c23%22:%91%22title_container_bg_color%22%93}"][/pac_divi_table_of_contents]

Intake at a Lactation Visit

Here are a few methods:

  • Unscripted note taking
  • Using a paper intake that the LC asks and fills in during the visit
  • Using a software with built in intake fields that the LC asks and fills in during the visit
  • Reviewing a mom's answers to an intake form that she filled out prior to the visit

 

When it comes to intake in my visits, I use a hybrid method. I prefer to use a notebook (my Supernote digital notebook) and take notes, but I do have a bit of a script that I use to get the most important information that I need to understand the situation. 

I never send my patients intake forms to complete ahead of time. While it seems like it may save time, in reality, it doesn't. I am going to have to read through the form and ask questions to get clarification from the moms during the visits, anyway, so it doesn't save me time. It also creates extra work for new moms who are already overwhelmed, sleep-deprived, and most-likely in pain.

I want the process to get care from me to be as simple and painless as possible. 

I don't like the process of sitting behind the computer or ipad asking questions and filling in the questions in the software for a couple of reasons. First, I think the process is very formal and takes my eyes off of the mom. Second, I think it inhibits my critical thinking. If I'm going down a checklist, filling in the blanks, I'm likely to miss some of the more nuanced information mom may give, especially if there is no easy place to capture that in the software. 

Software for LCs is a great tool for charting, but I don't think it belongs in the visit. Save it for after your visit when you need to create your formal chart notes and care plans. 

Intake Questions

Mom:

  • Gs/Ps
  • Age
  • Were there breast changes in pregnancy?
  • Notice colostrum in pregnancy?
  • Hormone problems? (thyroid, infertility, PCOS, etc.)
  • Any breast surgeries/ procedures?
  • GDM?
  • Lactation history?
  • Breastfeeding goals?
  • Back to work?

Baby:

  • Delivery complications?
  • Birth weight
  • GA
  • How did baby feed in the hospital?
  • Any BS, Bili, weight loss issues?
  • Diaper output in last 24-hours
  • Current feeding plan

Birth:

  • Delivery type
  • Lots of IV fluids?
  • Excessive blood loss?
  • Blood pressure issues?
  • S2S after delivery? Latch after delivery?

These are just starting points. Of course if mom gives a yes answer to anything, I'm going to dig in deeper in order to understand the situation.

How I use my Supernote

  • I have used template that I created in Supernote with my intake questions. This works best when you're just starting out.  (Get a free copy of the template below.)
  • I also have just used a blank lined page. This works better after doing a lot of intake interviews.

    Why I love my Supernote

    • All of my notes in one place.
    • Many features that help you to be super organized.
    • I created a "notebook" in my Supernote for my patients. I name each note with my patient's name and I can easily pull up my notes from their last visit to see how things have changed, how much baby has gained, etc.
    • You can password protect your Supernote to keep all of your files safe.
    • You can sync with Google drive and never lose any of your notes.
    • Excellent battery life.
    • Writes like pen on paper.
    • So easy to erase mistakes.

    Effective note-taking is an invaluable skill in the realm of lactation consulting. By honing your ability to capture essential details efficiently and accurately, you enhance the quality of care you provide to each dyad. Remember, the notes you take are not just records; they are a reflection of your professional insight and a crucial tool for crafting individualized care plans.

    Do you want to learn my Method for History Taking at a visit?

     

     

    Click here to download the free guide.

    Learn more about Supernote here!