Mastitis, Engorgement, or Plugged Duct Lactation Note

Date/Time: [Encounter date and time]

Author/Credentials: [Clinician name and credentials]

Encounter Type: [in-person / telehealth]

Consent: [obtained / declined / not applicable]

Reason for Visit

"[Patient-stated concern in brief quote]" — [Clinician synopsis using mastitis-spectrum terminology]

Safety Screen

(Include for any breast inflammation complaint. Explicitly document presence or absence of each red flag; do not leave blank.)

• Fever/rigors: [present / absent]
• Rapidly progressive erythema: [present / absent]
• Severe systemic symptoms: [present / absent]
• Tachycardia: [present / absent / vitals not obtained]
• Fluctuant mass or purulent drainage: [present / absent]
• Immunocompromised state: [yes / no / unknown]
• Worsening despite prior treatment: [yes / no / not applicable]

Disposition: [Managed in lactation setting / Requires same-day medical evaluation / Referred to ED or urgent care] — [Rationale]

History

Symptom timeline and localization: [Onset date/time; postpartum timing; unilateral vs bilateral; location/quadrant; pain severity 0–10; skin changes; systemic symptoms]

Feeding and milk removal pattern: [Direct feeding frequency, duration, side preference, recent changes; pumping details if applicable: device, flange size, suction, frequency, duration, volumes; milk flow issues; missed feeds or schedule disruptions] (Document "unknown" for unavailable details rather than omitting.)

Infant feeding effectiveness: [Infant age; prematurity/NICU status; weight concerns; diaper output; feeding behavior changes] (Include when latch or transfer may be contributing.)

Prior episodes and treatments: [Previous mastitis/abscess including recurrence at same location; prior antibiotics with agent, dose, dates, response; supportive measures attempted; breast procedures, piercings, implants, or trauma]

Relevant health context: [Medication allergies; current medications; significant comorbidities; immunocompromised status] (Document only items explicitly discussed; do not infer negatives.)

Exam

(Include for in-person exams. For telehealth, document patient-reported findings and specify what could not be assessed.)

Vitals: [Temperature, heart rate, blood pressure, respiratory rate, SpO2] (If not obtained, state "vitals not obtained." Do not assume normal values.)

General appearance: [Well-appearing / ill-appearing / distressed]

Breast exam: [Erythema pattern (segmental/wedge vs diffuse); warmth; edema; induration; palpable mass; fluctuance; tenderness severity and boundaries]

Nipple/areola: [Trauma; fissures; blebs; dermatitis; drainage]

Axilla: [Lymphadenopathy present / absent / not assessed]

Telehealth limitations: [Elements not assessable; threshold for in-person evaluation] (Include only for telehealth encounters.)

Feeding Observation

(Include when a feeding or pumping session was observed.)

• Latch and positioning: [Observations]
• Suck-swallow pattern: [Rhythm and coordination]
• Maternal pain during feeding: [0–10 scale and description]
• Milk transfer: [Observed signs; pre/post weights if obtained]

Assessment

Primary Diagnosis: [postpartum engorgement / ductal narrowing / inflammatory mastitis / bacterial mastitis (suspected) / bacterial mastitis (confirmed) / phlegmon / abscess / galactocele / subacute mastitis]

Contributing Factors: [Hyperlactation/oversupply behaviors; increased pumping or attempts to "empty"; nipple shield use; poor latch/ineffective transfer; missed feeds; nipple trauma/blebs; other identifiable drivers]

Differential Considerations: [Abscess vs galactocele; dermatologic mimics; inflammatory breast cancer concern with rationale] (Include only if presentation is atypical, recurrent at same site, or not improving.)

Plan

(Organize by problem. Distinguish actions within lactation scope from those requiring medical evaluation or prescriber involvement.)

Supportive Care and Milk Removal Strategy

• Milk removal approach: [Physiologic, on-demand feeding; comfort-focused expression; avoid "emptying" goals]
• Anti-inflammatory strategies: [Cold application; analgesics with dosing if applicable]
• Counseling provided: [Avoid deep massage, vibration devices, and aggressive pumping]
• Patient plan: [What patient agrees to implement]

Pumping Guidance

(Include when patient pumps or is separated from infant.)

• [Frequency and duration targets; flange sizing; suction recommendations]
• [Plan for affected side if pausing or reducing; strategy to protect supply]

Medical Evaluation and Antibiotics

• Evaluation threshold: [Criteria for same-day medical evaluation vs close follow-up]
• Antibiotics: [If prescribed: name, dose, frequency, duration, start date; adherence barriers; lactation compatibility] [If not prescribed: rationale and monitoring plan]

Diagnostics and Imaging

(Include when indicated or ordered.)

• Milk culture: [Indication; ordering clinician; collection instructions]
• Imaging: [Ultrasound or other modality; indication; referral destination; urgency]

Abscess Management

(Include when abscess is suspected or confirmed.)

• Referral: [Destination and urgency]
• Feeding guidance: [Wound coverage; avoid infant contact with drainage; pumping/feeding plan]
• Follow-up: [Timing after drainage]

MRSA Precautions

(Include when indicated: MRSA history, household exposure, recurrent infections, healthcare worker, NICU infant.)

• [Breastfeeding precautions; wound coverage; temporary milk discarding if advised; pediatric/NICU coordination]

Mental Health Support

(Include when distress noted or screening performed.)

• Screening: [Tool used; result; immediate safety concerns]
• Resources: [Referrals or resources offered]

Follow-Up

(Required section. If timing not specified, default to 24–48 hours for mastitis concerns.)

• Planned follow-up: [phone / telehealth / in-person] in [interval]
• Return sooner if: [Worsening pain or redness; fever or rigors; new fluctuance or drainage; expanding erythema; no improvement in 24–48 hours; concerns about supply or infant intake]

Education Provided

• Topics covered: [Supportive care; milk removal strategy; medication safety; warning signs]
• Resources provided: [Handout titles or links]
• Understanding confirmed: [Patient verbalization or teach-back; remaining questions]

Care Coordination

(Include when referral or escalation occurred.)

• Referrals: [Destination; urgency; orders placed vs recommendations only]
• Clinician communication: [OB, PCP, pediatrics, breast surgery, or imaging contacted]
• Safety net: [Instructions if timely appointment not available]

Electronic Signature: [Clinician name, credentials, date/time]

Addenda: [Document corrections with date/time stamp; do not overwrite original entries] (Include only if addendum needed.)