Lactation Follow-Up SOAP Note

Date/Time: [Date and time of encounter]

Clinician: [Name and credentials]

Encounter Type: [in-person / video / phone]

Patient of Record: [infant / lactating parent / dyad]

Reason for Visit: [Stated reason]

Subjective

(Capture interval history concisely. Omit items not relevant to this visit rather than marking N/A. Clearly label maternal information when documenting in an infant chart.)

[Chief concern and parent's stated goal for this visit]

• Interval feeding pattern changes: [Frequency; duration; clustering; night patterns]
• Supplementation status and changes: [Indication if stated; type; volume; method; timing] (Include only if applicable.)
• Elimination trends (past 24h): [Wet diapers count]; [Stools count and color/transition]
• Reported weights since last visit: [Home scale values with dates] (Include only if provided.)
• Response to prior plan: [What was tried; what helped; what did not; barriers encountered]
• New infant concerns: [Lethargy; excessive sleepiness; jaundice changes; spit-up; other] (Include only if reported.)
• New maternal concerns: [Nipple/breast pain course; engorgement; lumps; fever; pumping changes] (Label as maternal data when charting in infant record. Include only if reported.)
• Safety screening: [Infant red flags denied or present]; [Maternal red flags denied or present] (Include only if screening performed.)

Objective

(Begin with growth metrics. Do not auto-normalize components not assessed; explicitly state "not examined" when applicable.)

Growth metrics:

• Today's weight: [Weight with units] [Scale context: nude/diaper; clinic/home scale]
• Percent change from birth weight: [Percent value] (If unknown: "unknown—plan to obtain from pediatric record.")
• Average daily gain since last reliable weight: [Value with units and timeframe] (Include only if calculable.)
• Elimination (past 24h): [Wet diapers]; [Stools and color/transition]
• Vitals: [Infant vitals if obtained]; [Maternal vitals if assessed for systemic illness concern] (Include only if obtained.)

Infant exam: [General appearance; tone; hydration signs; jaundice observation; oral exam findings including tongue movement, frenulum, suck as assessed] (State "not examined" for components not assessed.)

Maternal breast exam: [Nipple/areola inspection: trauma, cracking, blanching with laterality]; [Breast palpation: tenderness, induration, warmth with laterality] (State "not examined" for components not assessed.)

Observed feeding: (Include when a feeding was observed; if not observed, state why and whether planned for next visit.)

• Position and latch: [Position used; latch depth and seal; clicking present/absent; pain rating at latch]
• Transfer signs: [Audible swallowing; suck–swallow–breathe coordination; breast softening; satiety cues]
• Post-feed findings: [Nipple shape; infant response]
• Test weights: [Pre-feed]; [Post-feed]; [Net transfer] (Include only if performed.)

Pumping/equipment assessment: [Pump type; flange fit; yields; changes made] (Include only if assessed.)

Assessment

(Numbered problem list ordered by clinical priority: infant safety issues first, then maternal medical issues, then technique/supply issues. Include explicit statement on adequacy of intake when weight or output concerns are present.)

1. [Problem]: [Diagnosis or working diagnosis] — [improved / worsened / unchanged] since last visit

   • Evidence: [Key supporting findings from S and O]
   • Adequacy of intake: [Adequate / borderline / inadequate based on weight trajectory, elimination, observed transfer] (Include for weight/output concerns. If inadequate, state level of concern and need for escalation.)
   • Differential: [Brief differential] (Include only when multiple causes would change management.)
2. (Additional problems as needed, following same format.)

Plan

(Organize by problem or as unified feeding/management plan.)

• Feeding plan:
  • [At-breast frequency and approach]
  • [Supplementation if applicable: indication; type; volume; timing; method; criteria for when to supplement]
  • [Pumping plan if applicable: frequency; duration; goals]
  • [Criteria for weaning supplements if applicable]
• Symptom management: [Maternal nipple/breast care; guidance on conservative measures vs. seeking antibiotic evaluation] (Include only if applicable.)
• Education: [Key counseling topics covered; parent's stated goal and agreed plan; confirmation of understanding for high-risk instructions]
• Escalation criteria: (Required when any risk is present.)
  • Infant warning signs: [Poor feeding; decreased output; worsening jaundice; fever; ongoing weight loss; other signs prompting urgent contact]
  • Maternal warning signs: [Fever; spreading redness; severe pain; no improvement within specified timeframe]
• Follow-up: [Next check-in date/timeframe]; [Mode: in-person / telehealth]; [Data to bring: diaper log, weights, supplement volumes]
• Coordination: [Communication with pediatrician/OB/midwife]; [Referrals placed] (Include only if applicable.)

(Missing information: Omit sections that do not apply. For safety-critical unknowns—weight when intake uncertain, output in early newborn period, maternal fever when breast inflammation suspected—use explicit placeholders such as "not assessed today" or "unknown—plan to obtain.")