Lactation Consultation SOAP Note

Date/Time of Service: [Date and time of encounter]

Setting: [inpatient postpartum / NICU / outpatient clinic / home visit]

Consultant: [Name, credentials (e.g., IBCLC, RLC)]

Referring Clinician: [Name and role] (Only include if applicable)

Interpreter: [Language, interpreter ID] (Only include if used; otherwise omit)

Dyad Information:

• Parent: [Identifier per EHR context]
• Infant: [Name/MRN], DOB [date], GA at birth [weeks+days], DOL [postnatal age], birth weight [weight]

Consent: [Consent statement for lactation consultation and hands-on assistance] (If consent for any element was not obtained, state reason.)

Reason for Consult: [Primary concern in one line]

Subjective

[Brief narrative of chief concern in parent's own words, feeding goals, and priorities for today] (Include a short direct quote from parent. State goals such as exclusive at-breast feeding, combination feeding, pumping, and any timeline considerations.)

Parent Lactation History

• [Parity, delivery mode, notable delivery/postpartum complications relevant to lactation]
• [Postpartum day and course, including any separation from infant or significant blood loss]
• [Breast/chest history: prior lactation experience, surgeries, pregnancy breast changes]
• [Current symptoms: nipple pain (0–10), nipple damage/trauma, engorgement, redness/warmth, vasospasm]
• [Conditions potentially affecting supply and relevant medications/supplements]

(Document only lactation-relevant positives and negatives; reference chart for comprehensive history.)

Infant History

• Weight: [Current weight, percent change from birth] (If unavailable, state "Not available at time of consult" and note plan to obtain.)
• Feeding pattern (last 24 hours): [Number of feeds, duration, one or both breasts, infant behavior at breast]
• Supplementation: [Type, amount, method, indication, who recommended] (Only include if applicable)
• Output: [Voids/day, stools/day, stool color] (If unavailable, document and note plan to obtain.)
• Concerns reported by parent: [Arousal, jaundice, lethargy, other] (Only include if applicable)

Prior Interventions

• [What has been tried: positions, latch techniques, nipple shield, pumping, paced bottle, supplements]
• [Parent's perception of what helped or worsened]

Objective

Infant Weight

• Birth weight: [Weight]
• Current weight: [Weight], obtained [date/time]
• Percent change from birth: [Percent]
• Test weight: [Method, pre-feed weight, post-feed weight, calculated transfer volume] (Only include if performed)

Breast/Chest Exam

• Overall: [Fullness/engorgement, edema, erythema, tenderness with location, scars]
• Nipples/areolae: [Everted / flat / inverted], [trauma, abrasions, color changes, blisters/blebs]
• Hand expression: [Milk visible, ease of expression, parent comfort]

(If not examined, state "Not examined today" with reason.)

Infant Exam

• General: [Tone, arousal state]
• Hydration: [Mucous membranes, fontanelle]
• Oral exam: [Tongue mobility, frenulum appearance, palate shape, suck quality]

(Describe findings without diagnostic labels outside scope. If not examined, state reason.)

Observed Feeding Session

(This is the core of the lactation consult. If no feeding observed, state reason and plan to observe at next contact.)

• Pre-feed state: [Infant state: sleepy / alert / crying], time since last feed [duration]
• Position: [Cradle / cross-cradle / football / side-lying / laid-back], [infant alignment and support]
• Latch: [Mouth opening, chin contact, lip flanging, areolar grasp, seal]
• Parent comfort: [Pain at latch and during feed, 0–10]
• Suck-swallow pattern: [Rhythm, audible/visible swallows, need for compressions, infant fatigue, unlatching frequency]
• Nipple post-feed: [Rounded / compressed / creased], [blanching, new trauma]
• Satiety: [Infant cues and behavior at end of feed]
• Duration: [Which breast(s), approximate time on each]
• Interventions trialed: [Repositioning, asymmetric latch, breast shaping, nipple shield, SNS] and [parent/infant response]

Pumping Assessment

(Only include if pumping is part of current or recommended plan)

• [Pump type/model, flange size and fit, comfort, output per session, frequency and timing]

Assessment

[Summary paragraph: postpartum day, infant day of life, weight trajectory, presenting concern, key observed feed findings (position, latch quality, transfer indicators, pain level), and response to interventions trialed]

(Do not claim adequate milk transfer without supporting indicators such as observed swallows, output, weight trajectory, test weight, or satiety cues. Label source of key facts as "Parent reports," "Observed," or "Chart shows.")

Problem List

1. [Primary problem]

• Evidence: [Supporting subjective and objective findings with source labels]
• Contributing factors: [Relevant risk factors or barriers]

2. [Additional problem]

• Evidence: [Supporting findings]
• Contributing factors: [Relevant factors]

(Add additional problems as needed. Use descriptive language for infant oral findings rather than diagnostic labels unless authorized to diagnose.)

Plan

(Organize by problem. Every problem in Assessment must have a corresponding plan element.)

Problem 1: [Problem label]

• Feeding plan: [At-breast frequency goal with cue-based guidance; specific position/latch instructions based on what worked; switching sides; use of breast compressions; pain threshold for relatching; waking techniques if indicated]
• Supplementation plan: [Clinical indication; type (expressed milk / donor milk / formula); method (paced bottle / cup / syringe / SNS) with technique counseling; volumes or protocol reference; weaning criteria; monitoring plan; parent preference documented] (Only include if supplementation indicated or in use)
• Pumping/expression plan: [Indication; frequency and timing; technique guidance; storage education] (Only include if indicated)
• Nipple/breast care: [Wound care; topical products; engorgement management; red flags for escalation] (Only include if applicable)
• Infant support: [Feeding readiness cues; shorter frequent feeds if indicated; referral for oral-motor evaluation if needed] (Only include if applicable)

Problem 2: [Problem label]

• [Corresponding plan elements as above]

(Add additional problems as needed.)

Education Provided

[Topics covered: positioning/latch technique, signs of effective feeding, expected output and when to call, paced bottle feeding, pump use] (Document teach-back or successful parent demonstration when feasible.)

Coordination

[Communication with pediatrician/OB/nursing; orders or referrals placed]

Follow-Up

[Timeframe], [location/modality], contingency triggers for earlier evaluation: [decreased output, lethargy, worsening jaundice, escalating breast symptoms, persistent severe pain]