Table of Contents

1. Why Charting Matters for Doulas
2. What Belongs in Your Visit Notes
3. Best Practices in Doula Charting
4. What to Avoid in Your Visit Notes
5. Organizing Your Records & Additional Notes
6. How Charting Helps with Insurance, Audits & Payment
7. FAQs
8. Resources

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Why Charting Matters for Doulas

• Your visit notes give context to platforms like Loula or any billing service, showing what happened during a visit. If those notes reveal non‑covered services (or suggest medical services beyond doula scope), payment can be held.
• They become critical when health plans (or Medi‑Cal or other insurers) audit your work. Clear documentation helps you pass audits.
• They serve as a record‑keeping tool for your business, future clients, and in case there are questions later. Even though clients don’t see your formal visit notes, those notes are your professional memory.

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What Belongs in Your Visit Notes

Your visit note should be a brief but meaningful summary of each visit. It should include:

• How the client is doing (physical, emotional, support network, risk factors)
• What services you provided during that visit (what you actually did)
• Key details: date, time, who was present (partner, support person), specific support measures (breathing, positioning, comfort measures)

Here are examples:

• Prenatal visit: “Client is at risk for gestational diabetes, but otherwise pregnancy going well. Discussed birth plan, meal planning, partner support (partner is Henry). To follow‑up with handouts.”
• Labor & delivery: “Arrived to hospital at 4pm. Client in active labor, contractions every 3‑5 min. Led client through breathing, showed partner (Nisha) how to support physically. Delivery at 7pm with no medical intervention. Lactation support immediately after.”
• Postpartum visit: “Client feeling overwhelmed after partner returns to work. Physically okay. Discussed baby sleep schedule; helped with baby bath.”
• After miscarriage/abortion: “Discussed physical recovery. Provided emotional comfort and guidance on grief/loss.”

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Best Practices in Doula Charting

To make your charting strong, useful, and defensible, follow these practices:

• Keep additional, more detailed notes outside of your summary note. For example, if you work through a birth plan worksheet, keep that worksheet somewhere; in the visit note you might simply say “worked with client on birth plan preferences.”
• Write notes as close to the time of the visit as possible. Timeliness helps accuracy. If you must catch up, indicate that an entry is a late entry with date/time of what happened vs when you wrote.
• Be clear, concise, objective. Use factual descriptions: what the client said, what you did, what the client’s response was. Avoid medical or diagnostic language beyond your scope.
• Include informed choice discussions: note what you offered, what you discussed, what client chose. If something is refused, record that.
• Make sure your notes don’t mention medical diagnoses (unless you’re referring to what the client reports), prescribing, diagnosing, inserting medical devices, etc. Stay within doula scope.

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What to Avoid in Your Visit Notes

Avoid things that could cause issues with audits, billing, or scope confusion:

• Do not document non‑covered services in the same note as covered services. If you provide extra support outside what’s billable, keep those details in a separate document.
• Don’t include medical terminology like “diagnose,” “prescribe,” “administer,” unless you are actually licensed and within scope.
• Don’t mix up what you did with what someone else did (medical staff, nurses, doctors). Be clear about your role.
• Don’t over‑generalize (“doing fine,” “normal labor”) without specifics. Vague language can weaken your record.
• Avoid late or back‑dated entries without noting that they are late or adding correct timestamps and explanations.

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Organizing Your Records & Additional Notes

To keep your charting efficient and usable:

• Keep a central system or folder for visit notes. Whether digital or paper, make them easy to find by client, date, and visit type (prenatal, labor, postpartum).
• Keep supplemental documents separately: worksheets (birth plan, preferences), handouts shared, client forms, etc. These give depth but don’t need to clutter your core visit note.
• If using digital tools or software, ensure secure backups and good labeling. Ensure that you have versioning or audit trail if edits are made.
• Use consistent format across your visit notes (e.g. summary of client status, services provided, follow‑ups or recommendations)

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How Charting Helps with Insurance, Audits & Payment

• Clear documentation helps validate that you provided billable, covered services. Health plans often require proof. If your note describes non‑covered service or stray into medical territory, it may trigger a hold or denial.
• Audits by health plans or insurers can require you to produce visit notes. If your notes are ambiguous or missing required elements (who, what, how, follow‑up), you may lose payment.
• When billing (especially via Loula or similar), charting is often audited. Good notes reduce the risk of payment being held.
• Documenting follow‑ups, recommendations, emotional or physical status, partner support, etc., can show the value of your work and may support advocacy for higher reimbursement or for showing necessity.

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FAQs

Here are common questions doulas ask about charting:

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1.Are visit notes shared with the client?

No. Visit notes are not shared with clients; they are for your internal documentation and for audits or billing partners like Loula.

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2. How detailed should visit notes be?

Keep visit notes brief summaries: a snapshot of client status + what services you provided. Additional or more detailed worksheets or handouts are kept separately.

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3. If I provide non‑covered services, do I mention them in my visit note?

No. Keep non‑covered services entirely separate. You don’t want them mixed in with the covered‑service notes, especially for billing/audit.

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4. Is it okay to use medical terminology?

Generally no. Avoid terms like “diagnose,” “treat,” “prescribe,” “administer.” Describe what you did (education, emotional support, physical comfort measures) rather than what medical action occurred.

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5. What if I forgot to write the visit note right away?

You can write a late note, but clearly label it as “Late Entry,” include when the event actually happened, when you are writing it, and provide factual detail.

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6. Do I need to record time, location, people present?

Yes. Including date, time, who was present, where the visit took place helps provide context and supports reliability of the notes.

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7. Can I use a template for visit notes?

Yes. Templates can save time, but avoid filling blanks with generic or irrelevant content. Customize per client, per visit.

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8. What about emotional or psychosocial details? Are they relevant?

Yes. It’s part of holistic support. You can include emotional state, support systems, concerns, coping, etc. Just do so objectively and in your own scope.

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9. How long do I need to keep these records?

Check guidance from your billing service or payer. Many insurers and health plans require records to be retained for several years. For example, in some state Medicaid programs it’s 6 years or more for FFS, and longer for minors or managed care.

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Resources

• Washington State’s risk‑management guidance on charting for midwives and birth professionals for good examples of clarity, timeliness, and completeness. (washingtonjua.com)
• National Health Law Program’s Best Practices for Medicaid Coverage of Doula Care for tips on documentation and program design. (National Health Law Program)

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