Lactation Counseling Note (Time-Based Billing)

Encounter Details

Date: [Date]

Patient (Lactating Parent): [name, MRN or DOB]

Infant: [name, MRN or DOB]

Provider: [name, credentials]

Setting: [outpatient / inpatient / home visit / video / audio-only]

Telehealth Statement: [patient location (city/state)], [consent obtained], [privacy confirmed]. (Include only for telehealth encounters.)

Time Documentation

Total Clinician Time: [X] minutes on date of service

Direct Counseling Time: [X] minutes (or Start/Stop: [HH:MM] to [HH:MM])

Time Attestation: [1–2 sentence description of what time included (counseling/education, feeding observation, care coordination, documentation) and confirmation that separately billable services were excluded]. (Required when billing by time.)

Subjective

Chief Concern: [Patient-stated primary concern]

Feeding Goals: [exclusive breastfeeding / combination feeding / pumping-only / other stated goals; include return-to-work timeline if mentioned]

Parent History: [postpartum timing, breast/nipple symptoms with onset and trajectory, milk supply perception, pumping details (device, flange size, frequency), relevant medical history]. (Document "not available" or "records requested" for missing critical details.)

Infant History: [chronologic age, gestational age at birth, birth weight, most recent weight with date, output (voids and stools per 24h), feeding behavior concerns, relevant diagnoses impacting feeding, current supplementation if applicable (type, volume, method)].

Feeding Pattern: [frequency day/night, typical duration, positions used, audible swallowing, nipple shield use].

Objective

(Document only items actually performed/observed. Omit sections not done rather than defaulting to normal. Label findings as observed versus reported.)

Exam Findings: [Parent breast/nipple inspection findings], [Infant oral exam findings], [general appearance]. (Include only if exam performed.)

Feeding Observation: [positioning, latch quality, suck–swallow–breathe coordination, audible swallowing, maternal pain during feed (0–10), nipple appearance post-feed]. (Include only if observed.)

Pre/Post Weights: [scale used, pre-feed weight, post-feed weight, net transfer]. (Include only if obtained.)

Pumping Observation: [flange fit, pump settings, technique, comfort, skin changes]. (Include only if observed.)

Assessment

[2–4 sentence synthesis of dyad's main issues, key observations, and clinical impression]

• [Problem 1]: [Impression with supporting evidence]
• [Problem 2]: [Impression with supporting evidence]
• [Problem 3]: [Impression with supporting evidence]

(List problems in priority order. Include additional problems only if applicable. Include differential diagnoses only when they would change management.)

Plan

• [Problem 1]: [Counseling provided, interventions performed, specific home instructions with numbers/thresholds as applicable]
• [Problem 2]: [Counseling, interventions, home instructions]
• [Problem 3]: [Counseling, interventions, home instructions]

(Include additional problems only if applicable.)

Topics Addressed: [list of counseling topics covered, e.g., latch/positioning, pain strategies, milk supply, pumping education, supplementation plan, return-to-work, milk storage]

Referrals: [specialty and reason]. (Include only if indicated.)

Follow-up: [timeframe, mode, what will be reassessed]

Return Precautions: Parent: [fever, worsening breast erythema, escalating pain, systemic symptoms]. Infant: [poor output, lethargy, excessive weight loss, worsening jaundice]. (Tailor to the clinical situation.)