BFC - KM - Consult - Post Visit

Template-structuur

Dit is de structuur die Notat volgt bij het schrijven van de notitie van het bezoek — u vult deze nooit handmatig in.

(Please make sure to create the following document below, using the context that has been provided. Of note, the context provided is a pre-visit summary note based on a patient intake questionnaire, along with during-visit notes added by the clinician, and the recording of the visit provided today. Please use this to make an improved and detailed post-visit note that uses the pre-visit note context as a basis for this note, but please default to the most up-to-date)

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 lines summarizing the pertinent past medical history, the feeding challenges and the plan discussed today relevant to the primary feeding parent. Please focus on the changes to their current feeding/lactation plan, and any suggestions made moving forward. Please include a brief overview of the mother first, listing her gravida, para, aborta, recent type of birth, and how many days since this birth. (using DOB from infant information to calculate, then followed by past medical history, family history, and social history. Please include only the most medically relevant details from each section below, focusing primarily on the interventions and suggestions provided. Please make this as concise as possible, while remaining detailed, focusing on the assessment and plan rather than extraneous details and history. Please include up-to-date pertinent positives of medical history. If the subjective history/context says one thing such as no nipple pain, but in the visit endorses nipple pain, please use the most up to date information provided.)

Child - [Name]: (Create a professional yet concise 4 lines summarizing the pertinent past medical history, the feeding challenges, and the plan discussed today, all relevant to the child. Please focus on the changes to their current feeding/lactation plan, and any suggestions made moving forward. For the infant, state gender, age in days [using DOB provided if under 3 months old and then in months if greater than 3 months old]. Then, past medical history, past feeding struggles, reason for referral, and any other pertinent details from history are included. Please include only the most medically relevant information from each section below, focusing primarily on the interventions and suggestions provided. Please make this as concise as possible, while remaining detailed, focusing on the assessment and plan rather than extraneous details and history. Please include only pertinent positives in the medical history. Please list patients weight today. Please always comment on growth appropriate, the interval from previous weights and percentiles compared to today. if the context provided says one thing, such as growth is appropraite but today we determine growth is not appropriate as documented in teh visit today, please defer to the most up to date recent note/comment on an area)

Dyad Follow Up: (Please indicate date and time of next visit, if not available, indicate timeline and who will be booking as sometimes parents are to book as per their availaility, if it will in person or virtual and when and if any items must be completed before this schedule, such as going to physiotherapy, starting medication, completing labs or imaging. If not clear, assume all follow-up is in person unless explicity stated it will be virtual)
_________________________________________________________________________________________
DYAD Medical HISTORY
Primary Feeding Parent - [First, Last Name]: (Provide a Summary of Medical history in bullet points, starting with allergies, medications current, medications past, gyne history and include birth history and contraceptive history on same line, lactation/feeding history, past medical history, psychiatric history, surgical history, family history, social history. If patient denies substances, no need list. If patient has not details listed in one area you can write unremarkable. If no drug allergies listed write NKDA)

Child - [First, Last Name]: (Provide a Summary of Medical history in bullet points starting with allergies, medications current, medications past, gyne history, birth history, past medical history, psychiatric history, surgical history, family history, if vitamin K was not given bold in capitals. If patient has not details listed in one area you can write unremarkable. If no drug allergies listed write NKDA)
_________________________________________________________________________________________
DYAD SUBJECTIVE: history as of today

(In this section, please summarize all of the patient's subjective concerns, including those from the intake questionnaire copied and pasted into the patient context feature and the information provided in the recorded visit today.)
___________________________________________________________________________________________
DYAD ASSESSMENT & PLAN:

(Please summarize the provided patient context feature and previsit notes, focusing only on pertinent positives, making it as concise as possible, and including medical history relevant to 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, ensure a space between each subsection and ensure the date is under the heading. If the child or parent have additional conerns, not captured in the below sub headings, please create a seperate sub heading for these issues so they may be included in the assessment and plan. Use dashes for each item listed with a date))

PARENT CONCERN SUMMARY:
-(use dashes for each item)(Insert today's date before starting this section with a hyphen before starting this section. Please use the format “day-month-year. Following the date, document any other concerns or medical history being treated or followed, as well as any medications being used. Feel free to create a title for each bullet that applies to each issue, and add multiple bullets if other medical problems are ongoing, such as ongoing maternal blood pressure issues.)

-(use dashes for each item)(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:
-(use dashes for each item)(Insert today's date before starting this section with a hyphen before 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 
-(use dashes for each item)(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:
-(Insert today's date before starting this section with a hyphen before stating 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 with a hyphen before stating 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 with a hyphen before stating 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 GALACTOGUE USE: (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)
-(Insert today's date before starting this section with a hyphen before stating 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 with a hyphen before stating 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 with a hyphen before stating this section., and always include todays weight, make sure this is written before the birth weight.. Please use the format “day-month-year”. Add date of their birth as provided, and then write 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 with a hyphen before stating 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 also note any past feeding relationships or challenges, 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 with a hyphen before stating 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 CONCERNS:
-(Insert today's date before starting this section with a hyphen before stating 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: (on this line please include historical elements such as 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.)
-(Insert today's date before starting this section. Please use the format “day-month-year”. Start this section with that the suspected diagnosis is for the child's mouth as per the writer today.  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 as maxilliiary labial anklyloglossia.)

DYAD FOLLOW UP
-(Insert today's date before starting this section with a hyphen before stating 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.)
___________________________________________________________________________________________
DYAD OBJECTIVE: INITIAL FEEDING ASSESSMENT & EXAM
[Current date here (day- non-numeric month - year):]
Vital Signs: [Weight, height, head circumference, and other vital signs with units]
Physical Exam Results: [Relevant physical exam findings for parent and child]
Diagnostic Test Results and Labs: [Completed diagnostic tests and laboratory results]

Child Exam (please adjust the below is a comment is made in each section or an abnormality documented)
-Skin: Pink, healthy
-Hydration: well hydrated
-Muscle tone: Grossly normal 
-MSK exam: Grossly normal - spine intact, see "Infant Myofascial, Head & Neck Concerns" for any documented abnormalities  
-Cardio/Respiratory exam: Grossly normal, breathing rhythmic and regular
-Abdominal exam: Normal
-GU exam: No concerns identified by parents
-Development: Gross Motor: Normal, non concerning
-Bonding with parent: Observed, non concerning

Parent Exam:
-Breast/Chest Exam: NAD, healthy tissue, Axilla non-tender as per patient history
-H/N: PERLA, CN2-12 grossly normal, N EOM
-CVS/Resp: N color, no respiratory distress, skin well perfused
-Skin: N color, no rashes
-Neuro: CN 2-12 grossly normal, N gait, N movement of all limbs
-GI: No masses on inspection, no jaundice
-Affect: normal range, appropriate to context 
-Vitals, height, weight: see EMR

(Please complete the following exam based on the items dsicussed during the exam today, the items that do not have a macro please leave as is. If a section is not mentioned by the writer, please assume normal or adquate or appropriate or within normal limits)

Feeding Modality: (assume body feeding unless explicity states bottle feeding occured during the feed. Child may be bottle feeding at home as indicated in the intake form but did not observe in office)
Inspection - At Rest
-Congested Breathing: [|none - normal|noisy]
-Facial/cranial bones: [|normal|asymmetry]
-Mouth Posture at rest: [|Normal, closed mouth posture|Abnormal, open]
-Chin Posture: [|Normal|mandibular retrognathia noted]

Inspection - With Feeding
-Mouth Angle: [|narrow angle - less than 120 degrees|normal, wide angle - 120-180 degrees or more|unable to assess see above]
-Lip Seal: [|inadequate, tissue/bottle slips easily with traction|adequate, tissue/bottle does not slip easily with traction|unable to assess, see above]
-Lip appearance: [|unified tonel-normal |two tone|significant blisters present|blanching with feeding]
-Milk Leakage: [|observed|not observed-normal|unable to assess, see above]

Tongue Assessment: 
-Shape/Spread: [|round or square - normal|abnormal - cleft or notched|]
-Tongue Elevation/Resting Tongue Posture: [|abnormal - whole tongue below mid mouth (flat)|abnormal - edges above mid mouth (U shaped)|normal - tip above mid mouth (tip reaches to aveolar ridge with ease)]
-Protrusion: [|abnormal - behind gum|abnormal - over gum but no over lip|normal - over lip]
-Cupping: [adequate|inadequate]
-Lateralization: [Tip - normal|Edge only|]

Suck test: 
-Vacuum: [|adequate|inadeuate|cannot be adequately assessed due to age/developmental stage of child as greater than 4 months]
-Peristalsis: [|normal,  hythmic peristaltic movement|abnormal, irregular and non-rhythmic, with intermittent loss of suction (‘snapback’) during feeding]
-Two tone tongue: [absent - normal|present|]

Maxillary Labial Frenulum Assessment: [|Appropriate - restriction not observeed|prominent frenulum observed|prominent frenulum observed but unlikely to cause concerns with infant feeding|query restriction, repeat assessment required|unable to provide formal diagnosis in context of other factors, repeat assessment required]

Lingual Frenulum Assessment: [Appropriate- restriction not observed|prominent frenulum observed|unable to provide formal diagnosis in context of other factors, repeat assessment required|]
-Thickness: [|thin - appropriate|translucent|medium thickness, partial muscle fibre involvement|full thickness, suspect muscle fibre involvement]
Insertion site: [|floor of mouth - normal|near alveolar ridge|at alveolar ridge]
-Attachment site: [|abnormal - near or at tongue tip|abnormal - 25-50% tongue tip|behind 50% tongue - appropriate]

Palate Assessment:
Hard palate contour: concave
-Arching: [ |normal - no notable arching|moderate|high]
-Shape: [|normal - symmetrical|, asymmetrical|]
-Width: [|normal - within normal limits|, narrow|]
-Pharyngeal reflex: [|normal - within normal limits|abnormal - exaggerated, sensitive]

Soft palate:  [|not visualized on exam as no clinical symptoms of submucosal cleft, will re-assess if symptoms or signs develop|pink, midline uvula with no bifurcation noted|abnormality noted:]