Documenting what happens at a lactation consult is super important for so many reasons, but figuring out just want to say and how to say it can be challenging. In this episode, Annie and Leah will explain their approaches to charting and offer you tips and strategies for making this critical task less overwhelming. Whether you’re paperless or love your clipboard and folders, this episode will help you streamline your charting workflow and feel confident in your documentation. “It didn’t happen unless you write it down” In this episode, we will cover: -What is lactation charting? Get a clear, concise idea of what charting should be -Why do we have to chart our lactation consults? There are important medical and legal reasons for charting -What are the biggest challenges and time sucks when it comes to charting? -Charting can get in the way of life outside of your practice -So, how can we do it better? There are some strategies for making charting more efficient -What to include and what to leave out? Not everything needs to go into your reports - Learn what should and shouldn’t be represented This episode is sponsored by the Lactation Consultant Private Practice Toolkit. Listen to the episode to find out how you can get a 10% discount. https://paperlesslactation.com/toolkit If you like what you heard today, please follow us on Facebook: https://www.facebook.com/lactationbusinesscoaching You can email us questions and comments at hello@lactationbusinesscoaching.com.
Documenting what happens at a lactation consult is super important for so many reasons, but figuring out just want to say and how to say it can be challenging.
In this episode, Annie and Leah will explain their approaches to charting and offer you tips and strategies for making this critical task less overwhelming. Whether you’re paperless or love your clipboard and folders, this episode will help you streamline your charting workflow and feel confident in your documentation.
“It didn’t happen unless you write it down”
In this episode, we will cover:
This episode is sponsored by the Lactation Consultant Private Practice Toolkit. Listen to the episode to find out how you can get a 10% discount.
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If you like what you heard today, please follow us on Facebook and Instagram and leave us a review on iTunes. You can email us questions and comments at hello@lactationbusinesscoaching.com.
About Us
Leah Jolly is a private practice IBCLC with Bay Area Breastfeeding in Houston, Texas.
Annie Frisbie is a private practice IBCLC serving Queens and Brooklyn in New York City and the creator of the Lactation Consultant Private Practice Toolkit.
Many thanks to Stephanie Granade for her production assistance, and to Silas Wade for creating our theme music.
PODCAST TRANSCRIPTION DETAILS
Customer Name: Anniefrisbie
Date: February 1, 2020
Podcast Name: Lactation Business Coaching
Episode: 9 – Charting Tips and Strategies for IBCLCs
Length: 39:26 minutes
SPEAKER(S)
This podcast is brought to you by the Lactation Private Practice Essential Toolkit. Use code PODCAST for 10% off at paperlesslactation.com/toolkit
Annie: I'm Annie.
Leah: And I'm Leah.
Annie: And this is Lactation Business Coaching with Annie and Leah where we talk about the smart way to create a compassionate and professional private practice.
Leah: Let's dive in.
Annie: Well, hey Leah. How are you?
Leah: Hey Annie. I'm doing well. How about you?
Annie: I'm really good. I'm super excited for our topic today. Documentation.
Leah: Yes. This is such a good topic because I think it's an area where a lot of lactation consultants struggle, especially if you didn't come from a medically trained background, this kind of all foreign and we don't have requirements through our coursework to you have to take medical documentation, which leads a lot of us kind of figuring it out on our own or trying to find information out there. So I know we're not the end all, be all authorities on this, but I sure hope that we can kind of share what we've learned through the years and figured out along the way.
Annie: Definitely. And just we'll get this out of the way. This is for you, whether you are doing things with pen and paper or whether you're paperless or you're somewhere in between. So we're really hoping to address all the different ways that you might be keeping track of things during a client visit. So before we do that, Leah, I love your marketing tips. What am I going to be doing this week to make my private practice better?
Leah: This is kind of a reminder for everyone about ... we're going to be talking about documentation. Part of your documentation is sending out those reports of your visits and remembering that that is a very powerful marketing tool for you because it's keeping the work that we do in front of people who might not ever know we're doing this work behind the scenes. Unless the mom were to tell the paediatrician or her OB that she saw us, no one would know and they need to know, both for documentation but also because it's great that they know they have this resource. We show our knowledge through those reports. So we build our credibility and I think it's a really powerful marketing tool, and one way you can help it be even more powerful is to make sure that you have a clear logo on your report and sending over a fax cover that has your logo, if you're using a fax cover, making sure that also has your logo. So there's just those peak reminder of like, Oh, I've seen this before. When somebody sees a logo repetitively like that, that's what kind of starts to stick in their mind. And so it can be really powerful to just have that on every single thing that you're sending over. And I think that we can really boost our presence just by doing what we already have to do.
Annie: That's a great tip and a great reason to get that logo done if you haven't done it already. Whether you have found somebody on Fiverr or one of those websites or worked with a friend or just hacked around in Canva yourself.
Leah: There's some really wonderful tools out there for just kind of creating simplistic logos for yourself, or amazing resources online to where you can find pretty inexpensive graphic designers to do something up for you, and really if you have a vision, it's super helpful. That's what I did with ours.
Annie: I have seen some gorgeous logos when I've been working with people and if you really want to see, I'm just going to embarrass somebody, but Dawnalea Kneese has an amazing logo on her website at lavenderlactation.com so I don't know the designer she worked with, but it is just... every time I looked at it I was like, that is a great logo. So anyway Dawnalea, you've got a great logo.
Leah: That's awesome. That's so awesome. Well, let's start talking about documentation. It's a juicy topic because like I said, I think it's a hard one for a lot of us, and when we talked about our reporting episode, I think we talked about why reports are so important, but I really feel like it ties so much into why the charting is so important.
Annie: You can't have a report without a chart, and I think to start we should just kind of essentially define what charting is because it is something that when I first got started, I wasn't quite clear on what I was supposed to do. So I knew that I needed to be keeping track of certain things and I started out just thinking, well, these are things that I need to remember so when my client emails me and has a question about what happened during the visit, I can refer back to my notes and see what I told her and what we worked on. And then as I got further and further into my private practice and I was learning more, and I'm realizing I actually there's a lot more than I need to be documenting. It's not just things for me to remember because I also have to remember that they can ask to see their chart, at least here in the US we've got ... and I actually believe that is true for other countries where you have even more freedom of access to your personal information. Realizing that my client could ask for their chart at any point, I don't think I even knew that I had that right to ask my doctor.
Leah: I know, I know.
Annie: I didn't know. So then thinking, wow, how am I writing this? What if this baby grows up and says, I want to know what happened when I was a baby and they request their charts and what are they going to see that I wrote down? And then I went and took a nap.
Leah: It was so overwhelming.
Annie: So overwhelming, I know. It was a little scary.
Leah: My heart is beating a little faster right now.
Annie: So what are the main reasons that we have to chart our visits, just from a code of professional conduct point of view to be a good IBCLC? Why are we documenting what happens during a visit?
Leah: Well, definitely it backs up what we've recommended, so we're putting down what our observations are, what our assessment is, what our impression is, and our recommendations are then backed up with all of those other pieces that we put together to figure out this puzzle. And so I think that's a really big aspect of it is that yes, you can send a care plan, but then if somebody asks why are we doing X, Y, Z? You have that written down and backing up your plan.
Annie: A lot of people use the SOAP note format. I know there are different other different acronyms that all pretty much do the same thing, but SOAP is an acronym that stands for subjective, which means what the client is telling you is happening. So my baby isn't gaining enough weight or it hurts when I breastfeed. You're talking about things like what symptoms is she reporting to you? My nipples are bleeding or my baby's urine is concentrated whatever those subjective things, what they're telling you happened. It can also include the history. What happened during the birth? How was the pregnancy? What's going on in these early days of life and then objective are the things that you are recording. So what do you see, what do you feel, what do you hear? A feeding exam -what happened during the feeding?
Leah: And this is where you might be including more concrete like, the baby's having five stools a day or the breasts are hard in this area and soft in this area. More very detailed information about what you're exactly seeing.
Annie: And so if the baby poops when you're there, you can write down what the stool look like and then when you get to the assessment you're saying what do you think is going on? And that's a super critical part, and this is where we say we're not diagnosing. I hope everybody listening knows that diagnosis is outside of our scope of practice, at least from a medical point of view, but we can absolutely say things like I believe there may be a possible -- fill in the blank -- that we think that's what's going on. Why we are recommending this client do anything. Without an assessment, what reason is there to give the P, which is the plan? So you have to have an understanding of the situation from the client's point of view, you have to make your own objective observation, you have to make some decisions. It's also called medical decision making when you're in the US. What do you think is actually happening? You have to choose from different courses that you could take based on what you think is happening and then you have to tell the client what they're going to do next, which will include coordinating care with their other healthcare providers.
Leah: And this is so important also when we're talking about why are we documenting from certainly an ethical standpoint, but also if you're doing anything with insurance companies and really even if you're not in network with insurance companies, if there's an out of network claim, they might also request to see your documentation if the family is pushing for that out of network claim.
And that's also where when you think about, Oh, somebody else could be reading this. That's in the US that's who else could be reading it are the insurance companies, so it needs to be clearly understood. We also need to have things documented for liability purposes. So I know super common situation because this is something that we talk about all the time when we're together as lactation consultants. We are super clear with our clients. Here is your care plan. I want you to supplement your baby this much. I want you to make sure you do this. And then they don't do it and then you might see them, Oh my gosh, this was the one that kills me. When you see them posting in some breastfeeding group on social media where you're like, I told you what to do and by the way, don't respond to that. Don't ever respond to that.
Leah: Don't respond...ever, ever, ever.
Annie: The worst thing that can happen though is if we are working with a baby who's in trouble and we're telling parents that they need to supplement. And I think one of the things that can happen is that if they don't follow our recommendations to supplement and the baby ends up hospitalized for dehydration, we need to have it documented that we told the paediatrician the baby needed to be supplemented because we can't control what they do with what we tell them. If we tell them something, we've got to write it down that we told them.
Leah: Yeah, I always liked the adage I've heard this throughout the years is it didn't happen unless you write it down. You can just pretend like you didn't do any of that unless you wrote it down. So that's one way to know what should I put in my chart. Just know whatever you want to make sure happened in your visit, that's what you're writing down. Everything that you recommended and everything that actually happened in the visit.
Annie: So that word, everything is, that's the problem, right? We are totally losing our minds trying to get this done.
Leah: Ten pages later, I have written down every word that came out of my mouth in the entire visit, which is definitely overkill, although I think sometimes in the beginning it's helpful to do more until you really hone your skills in because more is better than less, I would say, but I think over the years then you kind of figure out what is strategically going to be the biggest points that I need to share here.
Annie: And here's where I think we're all really struggling, at least from my perspective. I've been struggling, but even reading ... there was an article that came out recently. I don't remember what it is, but we'll try to look it up and put it in the show notes that was talking about the challenges that doctors are facing and how they're staying up till all hours trying to get their charting done.
Leah: It;s not just us.
Annie: It's not just us. It is a problem and that you're not alone. We can try to figure out how to make it more manageable. So when you're using paper charts, there is a speed with paper charts that I think really can't be replicated when you go into an electronic charting system, because if you're just checking boxes on a form and it's all pretty standardized and right there, that can feel like it's really fast. But with that you can lose a lot of nuance because if that little space where you have to write something is too small, you're probably not going to write more than that. Or if you do, it's going to end up on a different piece of paper and you might not end up ever typing that up to send it to the paediatrician. So the problem with electronic charting is that like you've got all this space and freedom to write everything down and you could literally write a book, and then you're thinking, well how do I do this during the consult? Or you might say, I'm not going to do this during the consult. I don't want to be on a screen during the consult, but then I'm just going to make some paper notes and then you have to put them into your chart later. And what I hear is happening is that that's where people are getting hung up. I have to sit down and type this dang chart.
Leah: Yeah.
Annie: Why am I doing this? It's so hard. These multiple steps take up so much time.
Leah: Yes, and those multiple steps are really where I think we can shave off time. I think this is going to be a necessary evil for all of our time sucking things in our life. It's just one of those ones that's going to take time, but I think where we can shave off is the duplication of the work that you're doing. I think that's an area that I found most impactful on the work that I'm doing, where my chart is my report and it's all going in at the same time, so I'm not having an additional step of then creating the secondary documentation, which is your report.
Annie: I think a lot of the electronic platforms can do that for you. I know Mobile Lactation Consultant can do that for you and CHARM can do that for you, and even JANE can do that for you if you set your templates up the right way, and I think having that mindset of you're not duplicating work, you are writing the chart to be read by whoever might need to read it. The other thing you can do just to remember that while every family that we see is nuanced and individual and unique and beautiful and has all the subtleties, that stuff maybe doesn't all need to go on your chart, because really from a documentation point of view, there are only a handful of things that people are seeing us for and so you can set those up as templates in your charting document or as quick text that you save in Google docs or in your auto text on your operating system or in an app like Phrase Express, which is not working so well anymore, but I still love it. I still use it or whatever it is, but to say yes, she's telling me all of the things. You're giving her all the empathy for what she's feeling, but at the end of the day, what you really need to write down was how many times did the baby eat? You don’t necessarily need to put in all of the breakdown, and some of those times they show those to me and I’m like, I can’t do this math in my head
Leah: I know.
Annie: I don’t know how many times your baby ate.
Leah: It almost stresses me out because they will say, my little app tells me that on Sunday, the baby ate for 3 hours and 16 minutes, but then on Monday only ate for 3 hours and 40 minutes. What does that mean?
Annie: What does that mean? I don't know what that means.
Leah: I actually don't know what that means. But it's so funny because it's almost like it induces this other layer of stress that I'm like, do we really need to have that detailed information? And sometimes you'll decide what information needs to be added because it stands out. You know, if the mom says the baby was feeding for 3 hours in 24 hours, Monday and then Wednesday only fed for 30 minutes. That needs to be documented, so you have to use some judgment there on like this is pertinent information. This is mom just wanting to share her experience, her wanting to share what is going on, how hard this transition is for her. And that's wonderful because we're present for that. But that might not be what you want to take up the time. Documenting all the little details about that if it's not significant to what you feel is going on in the visit.
Annie: Right. To use the same example, if they are telling you my baby started eating at 5 and ate for 15 minutes and then was fussy, and I gave the right breast and then then she slept for 10 minutes and then I gave the left breast for 10 more minutes and then she cried. So she's going through the blow-by-blow and you're listening, you're not needing to write down all those times. You're listening for what is the big picture story she's telling, because her baby cluster fed from 7 to 10 or whatever it is. That you might need to write down, and so you start to think about what kind of decisions are you going to need to be making with this information? So if it's cluster feeding, that's cluster feeding. But if she's telling you my baby has eaten every 20 minutes for the last 3 days, and then you ask has your baby ever gone a longer stretch, and she says no, then that's a totally different picture. So just try to take a little step back and start to do a little bit of filtering.
Leah: Yes. I think that's really powerful. I totally did not do that in the beginning. I was literally writing down the play-by-play. I was writing everything down. That was when we were doing paper charts too.
Annie: Oh my goodness.
Leah: Yeah it was intense. It was so much writing and then I had a really hard time in filtering that into a doctor's report cause it was like, Oh my gosh, how am I going to take all this information and make it concise when I don't even know what, but over time you really hone in what is the most pertinent information, and what I have found is that I think of it like each family's a puzzle and you have all these different pieces and generally puzzles all have very similarly shaped pieces for most standard puzzles. But the way they all fit together and the picture that they create is different for every family. But those little individual pieces are pretty standardized. And so when we're talking about feeding frequency, how you would word that is going to be pretty standard. Mother reports baby is feeding typically 8 times per day. Something like that is pretty standard template that you're going to have where you could change the numbers up, but how you word that is really standard.
Annie: That's a great way. I love that metaphor because you're so right that you can have all these different pieces that make a different picture and then to expand on that, you could think of who is the picture for. So you've got the pictures for the care provider so you want to make sure that they can see the picture. So sometimes getting too granularly-focused on things that are super fascinating to us, like number of jaw excursions in a sucking, that's so amazing. Maybe nobody is interested in that or is that an actionable piece of documentation? Or is it sufficient to say inadequate jaw excursions or disorganized suck pattern? Is that enough information where when the paediatrician sees it to understand that something is going wrong, or are you dealing with a situation that's about to become super medicalized and you do need to have some really crazy detailed stuff because you need something really crazy medical to happen. So you make that decision. Likewise, your client's going to be looking at this. If she ever requests to see her chart, you really might want to be careful to say things like just how you're talking about what her breasts look like, or what is going on with her baby. You know, just thinking how much could this hurt her if she saw it?
Leah: Right. Or just how you word things, you know.
Annie: Just how you word things.
Leah: Yeah, I think that's really important.
Annie: Keeping things kind of vague. Say you have an anxious client and maybe she does want to request her chart right away and you've got all this super mega detail where she might look at that and be like, Oh my gosh, something is terribly wrong, and I'm not arguing against doing some of those, reporting on those things or observing those things or just thinking about is this something that is going to be beneficial for the client? Is it something that's required for what I am recommending or what I need to document for insurance, and if it's not, I would say it's okay to just summarize.
Leah: Yeah. Are those big picture statements?
Annie: Do you need this detail in order for the necessary decisions to be made? Are you going to need this detail if she comes back to you with questions about what happened? Is the paediatrician going to need this detail in order to make a decision about this baby's care? And if the answer is no, summarize.
Leah: Yeah, I like that. I like that approach. And coming back to my thoughts on this puzzle analogy that I was thinking of, it's really powerful if we think about it in broken down pieces like that because this could help with your efficiency because then you can have either standard phrases or standard templates for the phrases that you most commonly chart with. Like when I'm talking about our latch, I have the same sentence. I always write I assisted mother in achieving a comfortable latch through whatever technique we used, and then I'll say something about the baby was organized and efficient or the baby was disorganized or slow. So it's a very standard sentence. Oh actually it's two sentences so I just have text expander for that and then I just change just a couple of words in the whole thing, but the whole sentence is written already for me cause I say it in the same way on every single chart. But it's important information cause I want to remember what latching approaches we were using, and then I want to remember what my impression of the baby's feeding at the breast was, and I also want to have that statement in my report so for me, this is an important couple of sentences. So I made a text expander out of that, and using that and then putting different ones together that are those different little puzzle pieces, I might use one on a mom who has a plugged duct so that I wouldn't use on a mom who doesn't have a plugged duct, but it's like that little puzzle piece, so I'm going to plug that text expander in. Once I get done plugging all these little text expanders in, I have a whole picture made but I didn't have to sit there and type out 20 sentences to make my assessment on what I was seeing through the visit.
Annie: Any of those auto texts, they're going to save your life. You really need to have them set up in any platform and it's worth saying, okay, you know what, I'm going to take one consult chunk and not see a client, but I'm just going to sit and I'm going to put my protocols into text expanders or auto text or into my charting platform. You can use the lactation reminders in Mobile Lactation Consultant. You can make a template in CHARM. You can make another template in JANE, whatever it is, take that time. You can make it in Google docs. You can do it and sometimes you can even know in advance, well I'm definitely going to be saying this, that and the other and you can start slipping things in there. While the baby's having their diaper changed is a great time to do some copying and pasting.
Leah: Yeah, and I really feel like it's a great guide to have some kind of templates because those babies dictate our visits and you might walk in and the baby's screaming their head off and you don't get to go through your normal procedure that helps you stay on track and not miss anything. So when you have those templates, it really helps me to hit all the high points I always want to make sure I hit when I'm not, because you get distracted like something crazy is happening and you're like, Oh gosh, I need to go over this or I need to make sure. And so I love having the templates and then the text expanders that are on, I use MLC and I use both Phrase Express and I mostly use that for my care plans, but then I use just the Apple keyword thing has been so fast and it also goes onto my phone too. So if I'm ever speed charting on my phone for some reason I can use that as well and it's all still there, so I really like that.
Annie: I love that. I am a super big fan of any kind of thing that lets you copy and paste or writes up. I use Phrase Express because it pops up on my keyboard and I can just like zip, zip. Throw it in there. And I have my protocols all written out. So if somebody, for example, has nipple damage, I just give them, here's my standard nipple damage protocol, and that's something where it doesn't need to be individualized. There's really only a handful of things are going to do for your nipple damage. So here they are, and I have it written in such a way where I can, if there's one on there where I actually don't want her doing that, so for example, it'll talk about the Silverettes or whatever, but maybe she already has them or it's not the right situation for them. I can just delete that. It's easier to delete something.
So I would encourage you guys to think about what's easy for you and what's hard for you. So for me, hard for me is writing by hand. I have terrible handwriting. I can't read it afterwards. My hand cramps, I can't keep up, I can't decipher my notes. What also for me is just way easier than using a visual template in Mobile Lactation Consultant or JANE or even in CHARM is I am just a really fast typer. I'm a lightning fast typer and it's so much easier for me to sit and take notes and I can do it without looking. I can make eye contact with the mom. I can offer empathy while touch typing, and that's just because I was a Hollywood assistant for years and my boss dictated letters to me all day long.
Leah: I think that's what all us IBCLCs need to go have a stint over there for training purposes.
Annie: I mean, that really helped me so I recognize that's easy for me, but that's not easy for everyone. But if you are a fast typer, I would recommend just maybe do some speed typing lessons and try to think about that, and I will say this too, our families really are not going to have the same feelings about us being on a screen during the visit as maybe you might, if you're not of that generation. You might have different feelings about manners and etiquette when it comes to looking on a phone or looking on a tablet while you're talking to somebody, and I just would let you know that they don't feel that way about it. So if you're going back and forth between that, I'm looking into your eyes and I'm offering you empathy and I'm connecting and I'm here with you, and then turning away to type something on the phone, they can handle that switching, and it actually might help them feel more comfortable with you if there's actually a break from the intensity, and they're really used to taking breaks by looking at a screen.
So what you can do is though if you're not a fast typer and you really want it to be templated out and visual and you've got to set it up in your charting platform. Really get to know how Mobile Lactation Consultant lays things out. Set up your CHARM templates or your JANE templates so that you know where everything is on this template and I'm just tapping, filling things in. I'm typing a number here, I'm tapping that there and so you can really get that done quickly. And then saving the text expander stuff - that long stuff should be saved for your instructions. That is where we need to put a lot of detail and make sure we're communicating to them what we want them to know, giving them the right links and resources to back up our recommendations, but really just make it easier for yourself in the objective part especially. Save yourself time there.
Leah: Yeah, I definitely agree with that and I like having the extra structure, but I could see where free writing can be really powerful if you are good at just taking notes and kind of going with the flow. I really have to think out what do I want to write down right now? So that guidance kind of gives my brain a place to like, okay, I need to write down this. I need to write down this for this thing because I have such a tendency I want to write out way more than is needed. So having those little templates really helps me narrow down what information I want to make sure I don't forget or have documented on my chart. So when we're thinking about documentation, we're kind of going there right now, what is enough or what's too much, or how do we know we've covered all our bases? What would you say to a new LC that is like how will I know that I've done it right, or I've done enough? Or do I need to keep writing more?
Annie: I think you need to filter your decisions for documentation through three key points. I think you need to filter these through three key points. One is will this chart lead my client to self-efficacy? So if she reads what I'm giving her, can she do what I want her to do? Can she understand it?
Leah: Yeah. What you're recommending is understood from the charting.
Annie: Exactly, and then number two, am I effectively coordinating care with the other medical professionals who need to be involved in the care of this dyad? So is my documentation going to the actionable? And number three, is it going to help me remember what happened when this family comes back to me and asks me questions? Those are the three things that need to happen. Now if you are doing, say you're doing research or maybe you have a medical license and you're doing other things during a consult than an IBCLC without a medical license, or you're trying to gather data for a research project, you're going to have additional requirements. But for most of us who are doing these - I'm going to call them straight forward lactation consultant roles, even though they're not straight forward - I totally get it. Every single consult is insanely different and it goes a long way, but they are straightforward. You're just not doing a whole lot. So in terms of where you're funnelling this documentation towards, so to the client so that they can achieve self-efficacy with breastfeeding, to the other care providers so that they can make sure the baby or the parent gets what they need in order to be healthy and well, and then finally for you so that you know how to follow up and provide that continued care for them.
Leah: Right. And I like also to think of it or... I guess early on, this is something that somebody said to me. Say you fell off the face of the earth tomorrow, could somebody pick up this chart and take over care with ease, or would they have to start over and ask all the questions and dig into all the history? And that really helps me a lot of times think about, okay, they have a really complicated history and I want to make sure that I add a few more sentences about this because it's pretty complex. Or is it super straightforward and uncomplicated, unmedicated vaginal delivery with 20 minutes of pushing going to be super short on that, so that somebody could pick that up and confidently know I have all the information I need to continue on with care with this family. So it's another filter I think that you could think about using as you go through and making sure that you hit those high points of what the mother told you, what you saw, what your impression or assessment of the situation is, and then really documenting our plan. Like what did we tell them? When you're putting it for the doctor's report, you might not have every single detail of the plan but more like an overview. So I might say recommended supplementation at this volume, but I didn't put down, they're going to supplement by bottle and we use paced bottle feeding. All these little bitty details that the parents need and want to know, but the doctor might not as they're skimming through, see all that. So I think it can be helpful when you're charting to, again, of course these are little protocols, but I know when I'm sending the family a triple feeding care plan, it's standard. I have a standard protocol and so on my documentation, I'll have in the plan triple feeding plan and I know what that means, and other people do too and then what I sent the parents was that standard plan.
Annie: That's great. And I will say we're going to make a freebie for this episode and we will have a link in the show notes. We're going to give you some abbreviations that you can use. These are standardized medical abbreviations commonly used that any doctor or nurse will be able to understand and interpret. And so we're going to give that to you as a freebie. Check the show notes for a link.
Leah: Yes, because to that point, if you are charting and using a lot of your own shorthand, so say when a mom's using the nipple shield in your charting, how document that is you put NS. Nipple shield this, nipple shield that. Well, that's not a standardized medical documentation abbreviation when we're coming back to that filter of could somebody pick this chart up and take over where you left off? Not if they don't know what NS means, so either you need to have somewhere on the chart that when you write NS, right next to it you put nipple shield and then the rest of the time you can use that. But it has to be clear that your own personal abbreviations can't be used because it then leaves like what does this mean for this person, these three letters together?
Annie: Great. Yeah, totally. I'm definitely have been guilty of that. I like abbreviations.
Leah: I know. It was so nice to do the shorthand because you know what you mean, but nobody else is going to know what you mean. And for a mom picking up that chart, she might not understand that or an insurance company might not understand that. So we need to make sure that we're explaining ourselves well. So Annie, as we wrap up today, I know you have a tech tip for us to help us with some documentation.
Annie: My tech tip is especially for those of you that like to be super, super detailed in what you're recording for the physical observation portion, especially feeding records. So when you really like to get in there and count sucks in a suck burst, all of that, I would recommend using voice memos for those.
Leah: I love that.
Annie: Because they don't necessarily need to be read. So if it's something where the paediatrician doesn't actually need to know but I want to know, I want to document it. You can take a voice memo. You can store it if you have G-suite that's configured, if you're in the US to be HIPAA-compliant or it's configured to conform to privacy regulations, which it does very well. You can use Google Keep to store those as a link and then you just put a link into the chart to where you've stored that audio, and then when you want to revisit it, you can listen to it, but you're not having to take time to transcribe it. And you can look around for HIPAA-compliant voice memo apps. I've looked into a few. I haven't had a chance to really explore them deeply to know if we could recommend one, but there are some out there that seem affordable and easy to use. So I think especially for those...
Leah: That transcribe? Is that what you mean?
Annie: Yes, they will take those voice memos. Some of them will transcribe, some won't. They'll just store it, but a couple of them I looked at will actually type it out for you. So I would say, I know that a couple of you out there are really wanting to keep track of this stuff and I want you to keep track of this stuff because you can do great things with it and this might actually save time because what you don't necessarily need to be doing is going home and writing all that stuff down that night into the chart. You have it recorded as a voice memo. It'll be accessible for you to get to later.
Leah: And to that point with the voice memos, I've been known if I had a really crazy visit and I didn't get to write down as much as I wanted and I'm speeding off to my next visit, I will as I'm driving take a voice memo. No identifying information - I know who it is - cause I'm going to write it down later, but right then when it's fresh in my mind, just get all the key points that I want to make sure that I remember it later on if I didn't get to do my normal charting.
Annie: Yeah, that's great. I mean a lot of us can talk a lot faster than we can type or look things up on a template and you can store it that way. And so you could even maybe not have to record that, actually type it out if it's something that isn't going to need to be seen in that level of detail by the pediatrician or the clients.
Leah: I love that. Well thank you so much for that tip because I'm just peeking my mind like how could I incorporate some of that as well? Because I really liked that idea and I love that you can put a link in. I had no idea. Annie, you always surprise me with your amazing tips. I'm going to use this one as well every week. Well it has been great chatting with you this week and I look forward to our next time together.
Annie: It sure has. Me too. Take care, Leah.
Leah: You too.
Annie: Bye.
Leah: Bye
Leah: Thanks for listening to Lactation Business Coaching with Annie and Leah. If you liked this podcast, please leave us a rating and review on iTunes, Stitcher, Spotify, wherever you're listening right now. Don't forget to hit that subscribe button so you never miss an episode.