BFC - KM - SOAP - FU - Continous

Template structure

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

DYAD VISIT SUMMARY:
-[Current date here (day- non-numeric month - year):] (Please summarize the below assessment/plan into a professional yet concise one-paragraph summary, starting with the date, no more than four lines, for their primary care provider, one for the mother, and one for the infant of the plan today, this is meant to send back to the referring care provider about what progress we have made, what we are still working on, what has stayed the same, and what changes we are making. Please include a single line for the referral reason and any previous interventions, so we have a clear summary of past visits. It can be concise. The purpose of this section is to provide context on past visits to any new provider stepping into the care relationship.)
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DYAD MEDICAL HISTORY:
(Include the past medical history for the primary feeding parent and child as provided in the context from the first visit. Please take a look at the example below. This would have been created during the first visit; however, please continue to add to these sections as new medical history becomes available, so we can keep them as up to date as possible as we move forward with the patients' care.

Primary Feeding Parent: 
-Allergies: 
-Medications current: 
-Medications past: 
-Gynecologic history: 
-Lactation/feeding history: 
-Past medical history: 
-Psychiatric history: 
-Surgical history:
-Family history:
-Social history: 

Child :
-Allergies: 
-Medications current: 
-Medications past:
-Birth history: 
-Past medical history: 
-Surgical history: 
-Family history: 
-Vitamin K IM administered: )

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SUBJECTIVE: [Current date here) [day- non-numeric month - year]
1. Parent Nipple/Areola/Breast/Feeding Discomfort: [Detailed history of parent nipple, areola, breast, or feeding discomfort, including onset, duration, severity, associated symptoms, previous treatments, and impact on feeding]
2. Parent Mental Health: [Description of parent’s mental health status, including any worries, concerns, mood, anxiety, stressors, coping strategies, support provided, and plan for follow-up. Please always include alot of details in this section and include any other parental worries or concerns)
3. Parent Lactation: [Details of milk supply, production, letdown, any issues with lactation, previous interventions, and goals]
4. Parent Galactogogue use [Details of use of prescription and herbal medication, common ones we use are Domperidone and Metformin. Note what dose they are taking, if their dosing has changed.]
5. Parent Mechanical Milk Removal: [Description of mechanical milk removal methods, frequency, devices used, fit and comfort, any issues, adjustments, and recommendations]
6. Child Growth: [History of child’s growth, weight gain, feeding frequency, any concerns, previous measurements, and parental observations]
7. Child Feeding/Tools: [Details of child’s feeding methods, tools used (bottle, nipple shield, etc.), any difficulties, changes, and parental feedback]
8. Child Behaviour and Symptoms: [Description of child’s behaviour during feeding, symptoms such as fussiness, crying, sleep, and any other relevant observations]
9. Child Myofascial/Headshape/Body Tension: [History of child’s body tension, head shape, neck movement, any therapy received, and parental concerns
10. Child Oral Motor/Tongue: [Detailed note regarding oral motor function, tongue movement, feeding challenges, and if frenectomy or follow-up is discussed, include questions, concerns, wound care description, follow-up interval, red flag symptoms, feelings, improvements, unchanged or worsened feeding, wound care completion, need to stop or continue, changes or struggles since last visit, step-wise plan, and goals of parent and provider]
11. Other Concerns/Notes: [Any other medical concerns discussed for parent or child, with detailed history, answers to provider questions, and robust subjective information. If multiple concerns, list as bullet points.]
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ASSESSMENT & PLAN:  (Global Rules to be followed
DO NOT label subsections with the words Assessment or Plan.
DO NOT remove, rewrite, summarize, reorganize, or correct any prior documentation provided in the context.
DO NOT add, infer, assume, or fabricate any information that is not explicitly provided in the context or today’s recording.
DO NOT alter wording, tone, formatting, or content of prior entries in any way.
DO NOT delete or condense historical notes.
DO NOT move historical entries out of their original subsection.
Use dashes for each item)

Required Structure:
For each existing problem-based subsection e.g., Discomfort, Lactation etc. Maintain the subsection header exactly as written, Immediately under the header, insert a NEW entry for today using the following format, using dashes and as concisely as possible):

-[Current date – day, non-numeric month, year] (Make sure to capitalize the date and always start with a bullet point. Provide today’s updated assessment and plan for this problem only. Incorporate and address any unresolved issues, concerns, or follow-ups carried forward from prior visits. Use prior documentation for clinical context, but do not restate it unless clinically necessary. Directly below today’s entry, include ALL prior entries exactly as they appear in the provided context, in chronological order, please start each entry with a bullet point, including:

Original dates, Original wording, Original formatting, Continuity of Care Requirement: Any previously noted outstanding concerns, incomplete plans, or follow-up items must be explicitly carried forward and addressed in today’s dated entry when relevant. Historical entries must remain untouched and serve as a running clinical log under each problem.

If No Update Is Needed Today: Still add today’s date under the subsection with a dash to start the sentance,  state clearly that there is no change from prior ass.essments, without modifying historical text and please summarize the previous note int today's note

For any new problem highlighted by the patients today, please create a problem-based subsection for this issue with today's date, use dashes for each item, and ensure this is moved forward as per the above notes for each visit)

-(Current date here in this format: day- non-numeric month - year and insert dash before section of text)(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. 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 DISCOMFORT: 
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text): (Assessment of discomfort, contributing factors, and plan for management, including specific treatments, medications with dose and duration, and follow-up. Include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note)

PARENT/FAMILY MENTAL HEALTH: (on this line include parents psychiatric history, psych medication use past or previous)
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text): (Assessment of mental health, support provided, reassurance, and plan for ongoing monitoring and follow-up. Include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note. Always include a lot of details in this section, if a longer lenghtier conversation is had, or both parents/support people are present, please document that a family conference occured to support the families mental health and flush out any ongoing treatment modalities in the plan each visit such as medications in use, even if no change to management and/or ongoing therapy interventions. If 2 adults are present in the room, such as a partner or support person, please indicate that a family conference was completed today discussing how to best support the family)

PARENT LACTATION: 
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text): (Assessment of lactation status, contributing factors, and plan for optimizing milk supply, including interventions and follow-up. Include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note)

PARENT GALACTAGOGUE: (on this line please include if the parent has any risk factors such as cardiac or mental health concerns that would preclude them from using domperidone and/or if they have any insulin resistance factors that would make them a candidate for Metformin)
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text):(Assessment of galactgogue use, dosing, side effects, impact, plan for adjustments, recommendations, and follow-up. Include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note)

PARENT MECHANICAL MILK REMOVAL: 
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text): (Assessment of mechanical milk removal, device fit, comfort, and plan for adjustments, recommendations, and follow-up. Include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note)

Child GROWTH: 
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text): (Always start with childs weight today in grams, calculate grams per day since last visit, and include percentile from last, then include an ssessment of child’s growth as in stable if within 3 to 5%, increased or decreased, adequacy of weight gain and plan for monitoring, interventions, and follow-up. Include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note)

CHILD BODY FEEDING: 
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text) (Assessment of body feeding, challenges, and plan for modifications, recommendations, and follow-up. include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note. Please include any details of breast feeding  in office today, volume tranferred, sides, suggestions to feeding position, feeding cues, please include all details related to this)

CHILD NON BODY FEEDING: 
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text):(Assessment of feeding methods and tools, challenges, and plan for modifications, recommendations, and follow-up. include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note. If an observed bottle feed was completed int he office today, please document these objective findings here and under objective section, as in what bottles was used, nipple, how much was transferred if pre and post fee weight was done, if a bottle top up was used or any other tool)

CHILD BEHAVIOR & SYMPTOMS: 
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text): (Assessment of child’s behaviour and symptoms, contributing factors, and plan for management and follow-up. Include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note)

-(Current date here in this format: day- non-numeric month - year and insert dash before section of text)(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. 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/MSK: 
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text):(Assessment of body tension, head shape, and plan for therapy, interventions, and follow-up. Include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note)

CHILD ORAL MOTOR: 
-(Current date here in this format: day- non-numeric month - year and insert dash before section of text) (Assessment/Diagnosis of oral motor function, tongue movement, feeding challenges, and if frenectomy or follow-up, detailed evaluation of procedure, wound care, feeding changes, plan for ongoing care, step-wise plan, and goals. Include all previous text from the first visit to today's current  visits on the lines underneath in this section so there is a running commentary of this section from first visit to day,  do not change any of the text in these sections and simply copy from last note)

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. Uses a dash to start this section and any previous section before the date)
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OBJECTIVE: [Current date here) [day- non-numeric month - year]
( f virtual visit, document only observed parent/infant appearance and engagement. Do not include physical breast/chest exam unless performed and directly observed." Remove any default physical exam language from virtual visit templates. Instead, use: "No physical exam performed; parent appears well via video/phone assessment.Unless physical exam findings are explicity reported please keep this section to only the pertinent findings so that if the writer does not indicate whether this is a virtual or in person visit, the charting in this section will still be appropriate. If an observed feed was completed today, include any and all observations regarding feeding at breast and/or bottle and if pre and post weights have been done for transfer assessment. Please also make mention of any other findings noted about the infant and/or parent that is relevant)