BFC - KM - Consult - Pre Visit Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

PRE VISIT: INTAKE VISIT SUMMARY: [Current date here (Number date- non-numeric month - year)], [Dr. Kelly MacGregor, MD or Dr. Tanya Schuman, MD, as per the introduction at the start of the visit by the writer.

Primary Feeding Parent – [Name]:
(Create a professional yet concise 4-line summary describing the key medical and lactation-related factors relevant to today’s visit. Begin with a brief obstetric snapshot—gravida, para, aborta, recent birth type, and how many days postpartum using the infant’s DOB. Then summarize only the most pertinent medical, family, and social history details that directly relate to today’s concerns, including allergies and medications beinto g taken currently. Focus on current symptoms, feeding challenges, and the primary reasons they are seeking care today. Do not include plans or future recommendations—this should strictly orient the provider to the parent’s present situation and relevant background. Include the specifics pertaining such as how much milk they are producing, if they are pumping, what pump, what kind, what size of flange, if they are taking any medications or herbals for milk supply, any risk factors that would put them at risk for low milk supply if they have seen another provider. Please include all positive responses and free-text items the patient endorses from their questionnaire.

Child – [Name]:
(Create a professional yet concise 4-line summary describing the key medical and feeding-related factors relevant to today’s visit. State gender and age [in days if under 3 months; in months if older]. Summarize only the most pertinent past medical history and previous feeding issues that inform why the infant is presenting today. Focus on current feeding concerns, symptoms, or challenges prompting evaluation. Exclude treatment plans or recommendations; this should strictly provide the provider with a clear understanding of the child’s present condition and relevant background. Include if the received IM vitamin K. Include any tools they are using, such as supplemental feeding systems, bottles, what kind, what nipple, formula, expressed breast milk and any medications the child is currently on or was previously on. Please include all positive responses and free-text items the patient endorses from their questionnaire.)
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DYAD Medical HISTORY 
Primary Feeding Parent - [First, Last Name]: (Provide a Summary of Medical history in bullet points. If the patient has no details listed in a given area, you can write 'unremarkable'. Please make this as concise as possible and use medical shorthand
-Allergies:  If no drug allergies listed, write NKDA. Please list any other allergy patient lists
-Medications: current, medications past,
-Gyne history with recent birth history and contraceptive history on the same line, 
-Lactation/feeding history
-Past medical history
-Psychiatric history with any medication use currently or in past
-Surgical history
-Family history
-Social history. If the patient denies substance use, you don't need to list it. 

Child - [First, Last Name]: (Provide a Summary of Medical history in bullet points. If the patient has no details listed in a given area, you can write 'unremarkable'. Please make this as concise as possible and use medical shorthand
-Allergies:  If no drug allergies listed, write NKDA. Please list any other allergy patient lists
-Medications: current, medications past,
-Birth History: Include type of birth, any complications and birth weight
-Lactation/feeding history:
-Past medical history
-Surgical history: include past frenectomy or frenotomy
-Vitamin K: Record if provided IM at birth and if not what type or if none write "NOT PROVIDED"
-Family history
-Social history. If the patient denies substance use, you don't need to list it.)
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DYAD SUBJECTIVE: Information compiled from pre-visit questionnaire and in-visit history

(In this section, I'd like for you to please summarize all of the dyad's subjective concerns in bullets as concisely as possible in medical shorthand for ease of reading. Please ensure you include the child's birth weight and any other weights provided. Please include only pertinent positives and the parent's free text. 
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DYAD PRE VISIT ASSESSMENT (this section is to create a structured note from the intake questionnaire to provide a scaffolding to the issues that will likely be discussed today, as the plan, please make comments on what is currently in use; however, this may change once the patient arrives for the visit and works with the clinician)

(Please summarize the provided intake questionnaire, copied and pasted into the patient context feature, focusing only on pertinent positives, making it as concise as possible, and including medical history relevant to each section. Please keep all summaries to the same line for each section. Please use the following sections to organize the information. In each section, please follow the instructions for organizing information by including this information; however, you may contain other information as it is provided and pertains to this section. When inserting dates as directed below, please use this format: “25-Nov-2026:” Please do not use brackets and do not put spaces between the sections below. Please use the information from today's visit to provide further context and detail for the assessment and plan for the following sections. The combination of these two information sources will help me create a robust note for the assessment and plan section.)

-(If a the parent has additional concerns, or relevant ongoing medical history such as a chronic disease, or ongoing medication use, or non related lactation or feeding cocnern please create sections for these concerns individually here and label it appropria. The formatting should following the below sections with insert today's date before starting this section. Please use the format “day-month-year. Following the date, include all relevant details they have provided. Example: the patient has chronic, well conrolled Chrones Disease.  Please create a section that documents this, state of disease, medications they are on. This will serve to remind the clinician about this concern at every visit. There can be multiple of these if required)

-Parent Contraceptive: (Insert today's date before starting this section. Please use the format “day-month-year”. If the parent requests contraception, please write “patient to book virtual contraceptive intake to discuss further.”)

-Parent Discomfort: (Insert today's date before starting this section. Please use the format “day-month-year”. Start with any risk factors. Indicate if endorsed or denied, what structures are involved, unilateral or bilateral, management strategies in use right now, not in past.)

-Parent/Family Mental Health & Coping: (Insert today's date before starting this section. Please use the format “day-month-year”. Indicate past mood history, medication use past or present. Then document what current concerns are today, if mood challenges present for primary feeding parent, any family or partner axiety, and if medications are currently being used, please comment on how the feeding journey may be aggravating or impacting their mental health. Please always end this area with family was supported and counselled. If feeding challenges are worsening the primary feeding parent or family mental health please indicate as such and how supporting this feeding dyad will work towards improving this)

-Dyad Sleep: (Insert today's date before starting this section. Please use the format “day-month-year”. Indicate where the child sleeps and whether there are any sleep concerns.)

-Parent Lactation: (Insert today's date before starting this section. Please use the format “day-month-year”. Start by indicating any lactation challenges, such as (if formula in use term hypolactation and demonstrate how much is used in 24 hours, when and why, indicate mild hyperlactation if storing > 4 ounces per day, if > 8 ounces significant hyperlactation, and Involution if no longer producing breast milk. If the parent has enough milk and no supplement is required, write “Sufficient.” Please indicate that the person desires to change their supply status. ) 

-Parent Galactogogue Use: (Insert today's date before starting this section. Please use the format “day-month-year”. Indicate whether they are using any prescription or non-prescription medications to increase their milk supply, such as herbal products [list which ones and doses if provided], domperidone/motilium, or metformin. Please indicate if they have any notable risk factors that would preclude or make them good candidates for use. Please take these risk factors for the lactation section. Most notable for domperidone, as no history of cardiac issues or severe mental health, if so, please note this and say “cautious use of domperidone due to”)

-Parent Mechanical Milk Removal: (Insert today's date before starting this section. Please use the format “day-month-year”. Start with if occurring, any pain, what pump, what flange, how often, and why. Please document any future plans for mechanical milk removal)

-Child Growth: (Insert today's date before starting this section. Please use the format “day-month-year”. Start with birth weight, always includeegestational age at birth, and note any growth concerns to date. If parent is maintaining growth and weight through unsustainable means, please indicate this and address the need for interventions as mentioned in the other sections)

-Child Body Feeding: (Insert today's date before starting this section. Please use the format “day-month-year”. Start with how breast/body feeding is going, how often, where, what challenges, tools they are using. Plans for improvement. Please comment on if the lingual or labial ankloglossia is impacting weight and if frenectomy will help improve growth. If observed feed done today, please comment on volume transferred, what breasts were used and if any concerning feeding behaviors were noted. If body tension is impacting ability to latch and feed at breast/body please comment, if lingual anklylogissia or maxillary labial ankyloglossia impacting drainage or latching at breast, please comment. If parent is feeding but in a unsustainable pattern please comment on this as while may appear normal is not and needs to be addressed. Please coment on any past feeding relationships or challenges, and if they saw a previous lactation medicine doctor or lactation consultant and if someone or they believe their child has a tongue tie.)

-Child Non-Body Feeding: (Insert today's date before starting this section. Please use the format “day-month-year”. Start with how bottle or non body feeding is going, how often, where, what challenges, tools they are using. Plans for improvement. If not currently bottle feeidng, please indicate any future plans to bottle feed. If child is old enough to be consuming complimentary solids, please document whether there are any concerns related to this and any mangement plan or assessment provided today. )

-(If a the child has additional concerns, or relevant ongoing medical history such as a chronic disease, or ongoing medication use, or non related lactation or feeding cocnern please create sections for these concerns individually here and label it appropria. The formatting should following the below sections with insert today's date before starting this section. Please use the format “day-month-year. Following the date, include all relevant details they have provided. Example: the patient has known or suspected gastroesopahgeal reflux.  Please create a section that documents this, state of disease, medications they are on. This will serve to remind the clinician about this concern at every visit. There can multiple of these if required)

-Child Myofascial, Head & Neck Concerns: (Insert today's date before starting this section. Please use the format “day-month-year”. Describe any pertinent positives, if they are seeing a provider and any risk factors. Please indicate if home exercises have been advised and if an issue is present in this section, please comment under body feeding if it is impacting ability to latch)

-Child Oral Motor Fucntion: (Insert today's date before starting this section. Please use the format “day-month-year”. Please ensure to include if family or other providers are concerned about tongue tie or lip tie, if a previous procedure was done, when, how and by whom, if vitamin K was given, and if any risk factors are in history. Make not if Ninni Co. Pacifer is going to be used for oral motor strengthening. When referring to tongue tie please use the word labial anklyloglossia and lip tie maxilliiary labial anklylogissia.)

-Dyad Follow Up: (Insert today's date before starting this section. Please use the format “day-month-year”. Indicate what follow up date, in office or virtual and the topics to be addressed. And what action items should be completed before this visit, if any.)