In the specialized field of lactation consulting, precise and detailed patient documentation is crucial. Properly formatted clinical notes not only enhance patient care but also ensure clear communication among healthcare providers. Here, we will delve into how to effectively write and format lactation consultant reports, using a Peds Report Initial as our template, and explore how AI medical scribes like Notis can streamline this process.

Begin your report with a clear subject line that addresses the referring physician. For example:

Dear Dr. Emily Johnson,

Next, introduce the patient and the context of the consultation:

Re: Baby Emma Smith

I had the privilege of meeting with Emma and her parents, Sarah and John Smith, for a breastfeeding consult on October 15, 2023. Weight in a clean, dry diaper was 7 lbs and 8 oz. Transfer of milk at the breast was approximately 2 oz.

Follow this with a detailed Subjective section where you describe the family's concerns and observations:

Emma's parents have brought forth concerns regarding her difficulty latching and frequent crying during feeding. The family has observed symptoms such as fussiness, prolonged feeding times, and inadequate weight gain.

Move on to the Objective section, documenting your findings during the examination:

I suspect a shallow latch and possible tongue-tie as indicated by Emma's difficulty maintaining suction and the clicking sounds during feeding.

In the Assessment part, provide your professional opinion based on the subjective and objective data:

A comprehensive care plan has been devised.

Finally, detail the Plan of action that includes recommendations and follow-up measures:

The recommendations I propose are as follows:

• Encourage skin-to-skin contact before feeding to promote relaxation.

• Use a nipple shield to assist with latching.

• Schedule an appointment with a pediatric dentist to evaluate for tongue-tie.

• Monitor weight gain weekly to ensure adequate intake.

Conclude with contact information and a follow-up schedule:

Parents are encouraged to reach out with questions and we have a follow-up scheduled for October 29, 2023.

Please reach out if you have any questions. Our phone number is (555) 123-4567 and fax is (555) 987-6543.

Thank you,

Laura Thompson

Incorporating AI medical scribes like Notis can revolutionize the way lactation consultants manage patient documentation. Notis is designed to reduce administrative burdens, allowing healthcare professionals to focus more on patient care.

Notis significantly reduces documentation time by up to 80%, saving about 2 hours per day. Its integration with WhatsApp ensures a seamless transition without the need to learn new software, making it a user-friendly option for lactation consultants.

Leveraging advanced voice-to-text technology, Notis offers 99% accuracy in transcribing medical notes. It generates structured SOAP notes from consultations, ensuring comprehensive and organized patient records.

Notis supports 56 languages, catering to diverse patient populations. Its smart search feature allows retrieval of patient information using natural language queries, making it easier to manage and update records.

In summary, utilizing AI medical scribes like Notis can enhance the efficiency and accuracy of patient charting in lactation consulting. By automating the documentation process, consultants can dedicate more time to providing optimal patient care.