Wiki Auditing for Breastfeeding Clinic

[annaree529]

Hello. I am looking for a little guidance here, I am trying to audit for a provider who is running an Outpatient Breastfeeding Clinic. The patients sit with a Lactation Consultant and are also seen by the physician. It would be easier if time was being used, but it is not and the chart note is for both baby and mother. The 3 key components of the chart are being completed, but again the chart is addressing both mother and baby.

History -
age of baby, gestation, birth wt, current wt
experience breastfeeding, milk came in when,
# of feed per day, supplementing, pumping, type of pump

Presenting problem -

Physical Assessment -
Maternal Anatomical Issues (inverted nipples, nipples/widely spaced breasts)
Baby Anatomical Issues (tongue tied/torticollis/receding chin)

Feeding Assessment -

Problem list -

Plan -

I do not doubt the time spent warrants a higher level of service, but I am struggling with do I audit the chart as is including both information of mother and baby? do I audit just for mother? just for baby?

I thank you for any advise offered as this is a new clinic for me and just not sure...