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Baby-Friendly and Electronic Medical Records

November 2015

Yes, I survived! The hospital which employs me as an IBCLC had its two-day Baby-Friendly Site Assessment this past week. As a lifelong seeker of new information, I learned even through my stress!!

One of the things which reinforced my current knowledge during this visit was documentation of details in your electronic medical records (EMR) to comply with the BFHI requirements. Currently, how does your facility document breastfeeding, skin-to-skin care, rooming-in, and supplementation for the mother-infant dyad? Take a look at the following and see if your facility has a coordination of documentation, or a lack of such:

medical record 620

  • Do your mothers keep an in-room documentation of feedings? If so, how are they marked...as feeding on cue, feeding to satiety, and signs of milk transfer OR fed well, fed fair, fed poor OR fed left breast 15 minutes, right breast 12 minutes? How are feedings recorded in your EMR? On cue, to satiety or well/fair/poor, or timed?
  • With skin-to-skin care (SSC) following all normal, uncomplicated deliveries, are you documenting times initiated, interrupted, and reinitiated? Do your interruptions have a rationale documented in the EMR?
  • Do you document continuous rooming-in? Are interruptions time-stamped and noted with a medical rationale for interruption?
  • Patient education on the Ten Steps should be documented, prenatally, during the hospital-stay, and for postpartum discharge. Are there locations in your EMR to note these various periods?
  • What about any type of supplementation of the breastfed infant...do you document the medical rationale, the parental teaching given, the type of supplementation given and the route used? Does your facility keep track of lot numbers, expiration dates, and patient contact information in case of a recall of the supplement?

Sue Bowman wrote an interesting paper regarding electronic health record (EHR) documentation and its effect on the quality and safety of patient care (Download the full paper at no cost here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3797550/pdf/phim0010-0001c.pdf ). She states, "Although EHR-related errors, and their actual and potential impact on the quality and usefulness of EHR documentation, quality and care, and patient safety, have been documented for years, much work still needs to be done to measure the occurrence of these errors, determine the causes, and implement solutions" (Bowman, 2013). Although this paper does not directly address the Baby-Friendly Hospital Initiative, you may find it useful as you continue on the Baby-Friendly pathway. Incomplete or incorrect documentation can count against you when your assessment visit occurs, as assessors will check your EMR against what the patient has shared with them.

Step2Education will be developing a course on charting for Baby-Friendly in the electronic medical records system within the next year. Keep your eyes open for this!


Kathy Parkes, MSN-Ed, RN, IBCLC, FILCA
Course Tutor, Step2 Education





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