Charting the breastfeeding/chestfeeding dyad: to separate or combine?


We care for more than one person in a lactation consult

Lactation visits are unique in healthcare because most of the time we’re working with a parent and their baby (or babies). That’s why in my book on private practice I compare our work to couples therapy. Our job is to bring two people together, and these two people may have very different times.

Combined goals, competing needs

In a lactation visit, we typically have two people who want the same thing, at least biologically. Lactation is a natural part of the reproductive cycle, and is meant to happen after delivery. Babies are meant to have reflexes and behaviors and drives that cause them to seek the breast to feed. Achieving full breastfeeding is an innate biological goal for both parent and baby. We all know how beautiful it is when this goal is met, and how stressful it can be when it’s not.

Many times, our job involves troubleshooting why these two people can’t work together, and often we are discovering that one or both parties have needs that may overwhelm the system and block the achievement of the goal of full breastfeeding. Some examples:

  • Baby has tethered oral tissues and needs to clamp onto the nipple in order to extract milk. When baby meets this need it causes pain and possibly trauma to the parent’s body. Now the parent has a secondary goal—to escape the source of pain—that may threaten the primary goal of breastfeeding.

  • Baby was suctioned at birth and there were minor injuries in the baby’s mouth. Baby may develop oral aversion out of a need to protect their mouths from injury, and this secondary goal—of keeping the mouth safe—conflicts with the primary goal of breastfeeding.

This is why it’s so challenging to decide if you want to chart the parent and baby together as one event, or create separate charting events so that each issue can be fully addressed.

Client privacy in the dyad

One important factor for us to consider is our client’s right to privacy and our ethical obligation to maintain privacy. Most digital privacy regulations allow citizens to request a copy of their medical records and clinicians are required to provide them.

That means that the baby you’re working with could one day request their lactation chart. How much information on their parent is it ethical for them to receive?

  • Breast size, shape, and appearance

  • Photographs of nipple wounds

  • Reproductive and sexual history

  • Surgical history

  • Psychological and emotional history

If you’re using a combined record for both parent and baby, think this through very carefully. The parent has an ethical right to know that their baby may someday see what she’s telling you. Will this affect what they disclose to you?

Technological considerations

Charting platforms all work a little differently, but some require you to decide how you’re going to manage the dyad.

ChARM, Simple Practice, Jane, IntakeQ, Practice Better and similar

In traditional EHR platforms that are not lactation specific, you’ll need to decide if you want to create a separate chart for parent and baby. Most platforms will allow you to link clients so that the charts are connected but still separated.

Because ChARM has built-in growth charts, a separate chart for the infant is essential to access this feature, because you need the birth date to plot the growth.

If you set up IntakeQ and Practice Better correctly, you are able to chart the dyad in one location, and then easily export baby-specific sections.

With separate charts, you may find yourself putting some information in more than one place. While any duplication of work is inherently inefficient, it may not have a significant effect on your workflow.

Lactation specific platforms: Mobile Lactation Consultant and MilkNotes

These platforms are created with the specific needs of lactation consultants in mind, and use a combined charting format. However, each allow you to generate separated reports for each member of the dyad.

For some US lactation consultants in-network with insurance and who are billing for both parent and baby, there is a concern that this is not enough separation in case of an audit. However, it seems from a privacy and ethical standpoint that separate reporting would meet those requirements.

Where does the feeding evaluation go?

If you have separate charts, does it go in the parent? Or with the baby? Or do you copy and paste for both?

IntakeQ, Practice Better, Milk Notes and Mobile Lactation Consultant are able to apply the feeding observation to both members of the dyad. In ChARM, Jane, Simple Practice, and others, you’ll need to choose one chart to put it in, and make a note in the other dyad member’s chart that you performed a feeding evaluation.

From a US insurance perspective, you will want to consider the definition of the procedure codes you’re using in order to make sure that your charting backs up the codes you’re using. In other words, the feeding evaluation may add complexity or time to an E&M code and you need to decide if you’re applying that time or complexity to the baby or to the parent.

The choice is up to you—and you take the responsibility

Ultimately you’re the one who needs to live with the charting decisions you’re making. Educating yourself on your ethical and legal requirements (like with my Toolkit) will help you choose the right technology to serve your specific needs. (That’s the kind of thing in IBCLC would say, right?)

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