Starting your private practice can be an exciting time, but it also comes with many questions…especially about charting! This post covers user-friendly charting tips for dietitians in private practice that you can start using right away…and you should!
One of the most important decisions to make early on is how you will document and chart patient data in order to save time, clearly communicate goals with your clients and maintain compliance with HIPAA regulations.
The following post is a robust round-up of tips, strategies and advice from real-world dietitians to boost your confidence. After reading this post, you’ll be able to get started with a charting personalized system that will help ensure proper documentation – without the stress – from day one!
For the full scoop on HIPAA compliance, bookmark our blog post: Unraveling HIPAA Compliance for Your Nutrition Private Practice.
What are client charts?
As a private practice dietitian, you have to keep a record of important information about your client visits. And while you can chart on paper, especially as you’re getting started, you will want to transition to an electronic health record (EHR) to increase your efficiency.
Your client chart will have a few important forms and documents for each individual client. Good news: we have templates for each of them.
- Consent form
- Financial agreement
- Getting Started Forms for Private Practice
- The Charting Template Bundle
- Client Welcome Guide for Practice Better
And once they’re established as a new client, you’ll be creating a new note for each one-on-one client visit, whether it is in person or virtual. This blog is focused on the charts that you’ll be writing during each visit with tips and templates to save you hours of time.
And while this article is focused on individual nutrition counseling visits, we have you covered with the right templates if you work with groups! Check out our Group Program Template for Practice Better if you’re interested in working with groups.
What are the benefits of an electronic health record (EHR)?
EHRs are a secure, one-stop-shop to store all your client documentation, making it easy and convenient for you to access it at any time. EHRs allow you to track progress with your clients and provide metrics on how they improve over time. Lastly, if you need to submit information to an insurance company or physician, EHRs make it easy to transmit the information quickly.
There are many options for EHR software these days and trying to compare one to the next can quickly cause one to approach overwhelm. Before exploring the bells and whistles of the different programs, write down a list of what features are crucial for your business and use that to explore the different options. Our blog post the Best Nutrition Software and Apps gives you a comprehensive round-up of the options.
Practice pearl: most software programs offer a free trial. Take advantage of this opportunity so that you can see which EHR feels the most intuitive to you and has the features that match your business needs.
What should I include in my charts?
There are certain pieces of important information you need to keep track of for each client visit – and they’re likely to differ depending on your specific niche and client goals, which doctors you network with and which insurance companies you bill to.
Initial client visit
The chart note for an initial client visit will most likely be your longest, most detailed note, while your follow-up notes will be more succinct. Your notes need to include the information that is necessary for you to provide effective nutrition recommendations.
Items to consider in your initial client visit documentation:
- Client’s full name
- Date of birth
- Date of visit
- Pertinent medical history
- Pertinent labs
- Medications and supplements
- Pertinent anthropometric data
- Dietary patterns
- A dietary recall
- Nutrition, health and wellness goals
- Physical activity
- Lifestyle information such as occupation, hours worked, sleep habits, stress levels
- Interest and availability to cook
- Grocery budget
- Long-term goals
- Goals for next visit
- Resources provided
- Length of time providing direct patient care, visit start/end time
- Where the visit occurred, office or telehealth
Practice pearl: it’s completely normal to feel daunted by running (and documenting) an initial session. Rely on the expertise of others and you’ll form your own unique workflow with time and practice. This Intuitive Eating Client Session Guide is a perfect example of a shortcut you can use to boost your confidence and efficiency.
Your follow-up notes are going to be shorter. And with the tips and tricks we have collected later in this post, you’ll save time writing them!
Items to consider including in your follow-up notes:
- Progress on the previous goal
- Barriers to making progress, if applicable
- Client wins
- New medications, labs or anthropometric data
- New goals set
- Date of next visit
- Resources provided
- Length of time providing direct patient care, visit start/end time
Now that we’ve discussed the various things that might be a good fit to include in your note, the next question is, how long should your initial and follow-up charts be?
How long should chart notes be?
There is no right or wrong answer here but consider brevity to be your friend. The longer you write your notes, the more time that they’ll take to create.
Aim to have enough information documented that you’re able to remember the important details that allow you to provide excellent continuing nutrition recommendations. But not so much information that you’re documenting information that isn’t necessary for continued care.
You’ll always be a bit slower at the beginning of learning a new skill – including charting – and that is to be expected. But with practice, you’ll be able to get through them more quickly. As you get to know your EHR software, you’ll also learn shortcuts to save time. Ideally, you should be able to complete most of your charting before the visit begins and while you’re with your client.
One final thing to keep in mind is that this charting is not paid time. As a private practice owner, you only have so many hours available in the day to bill for your services to meet your revenue goals. The longer you spend charting, the less you’re making per client visit.
Do I have to write a PES statement?
PES statements (or Nutrition Diagnosis Statements) are structured sentences that describe the specific nutrition problem that as the dietitian, you are responsible for treating and working toward resolving. The PES statement includes the cause(s) of the problem and the evidence that this problem exists.
A PES statement is not a medical diagnosis. Creating a medical diagnosis is outside of our scope of practice as registered dietitians.
A PES statement is needed for all nutrition assessments in a hospital setting, but it may not be required in a private practice setting. If you’re seeing self-pay only, the decision is up to you.
If you plan to bill for insurance, check with the individual providers to see what their guidelines are. Be sure to match their guidelines for a smooth reimbursement process.
Do the PES statements help to clarify the recommendations that you’re making? Then keep using them. If not, you get to decide to use something else that better serves your time and business model.
If the ADIME format, complete with a PES statement is a great fit for you and your practice, the ADIME Nutrition Assessment Charting Form Template needs to be added to your shopping cart right away!
Help! I always feel behind on charting!
Do you feel like you’re spending more time charting than you are actually seeing your clients? Ideally, charting should be a time-efficient process that helps you document your client’s progress and not something that keeps you in the office late at night. We can help you to speed things up!
Charts can be customized and templates can really save you time. Try to get as much charting done while working with your clients as possible. The more often you switch from one task to another (or one client to the next) the more worn out you’ll feel. Try scheduling your clients with enough of a buffer between them so that you can fully complete their session and charts before the next client.
Prior to your client visit
You might be surprised by how much information you can get charted prior to the client visit.
Your session might also go more smoothly and more purposefully if you ask your clients to complete a pre-session before, as Jen Hernandez does:
“With practice better, I automatically send out a pre-session form that addresses some of the necessary things I want to cover. I then can upload into a session note template that includes other things I want to address. I add in a few notes during our session and then afterward I spend about 5-10 mins (if that) with the nutrition treatment plan summary- the section of my note that is shared with my client. I don’t chart any more than that! – Jen Hernandez, RD and owner of Plant Powered Kidneys
Psst: if you’re feeling frustrated by no-shows, be sure to get a policy in place that protects your time and financial goals. You can purchase our financial agreement form to protect yourself from no-shows.
During your client session
Using a template saves you from re-writing the same information again and again. A template also helps to ensure that you don’t forget to ask specific questions, which is especially helpful at the beginning of your private practice sessions and getting into a flow. It is normal to be a little bit nervous; having a good template can act like a script to keep you on track.
In your personalized charting template, prioritize checkboxes and drop-down menus as they take less time to fill in than typing or writing in sentences.
As you continue working with clients, you can copy and paste the previous notes into the next session; some of the information will not have changed, so this saves you having to fill in that information again from scratch.
Some charting software programs, including EPIC, Practice Better and Healthie, allow you to program in commonly used phrases. After you type in the phrase, the program fills in the rest of the sentence! While this will take a little bit of time to program in, the time savings will be worth it!
“Creating an efficient charting process for either during or after the session saves so much time, energy, and assures you don’t forget to note any important information.
One way to do this is by charting in real time during the session. However, if you choose to do it this way, let your clients know that you will be doing this, especially if you’re doing virtual sessions. This will help them know what to expect during the session and know that you are still fully engaged in the session. You can also tell them that you are doing this in order to assure you capture important information during your conversation that will help create your plan for them.
What has been the most helpful for me is creating and utilizing a charting note template, so that I can easily plug in relevant information. This is much more efficient than typing in a blank nutrition note.
My initial and follow-up note charting templates are available on RD2RD so that other RD’s can use them and tailor them to their business. –Melissa Mitri RD, owner of Melissa Mitri Nutrition
Wrapping up after your session
The good news is that the better your template matches your clients, there shouldn’t be too much to wrap up after your visit!
But if you find that taking notes isn’t a good fit during your session, here are a few additional suggestions by Melissa Mitri:
“If you find yourself distracted by charting during, charting after the session may be better for you. I often take very rough hand-written notes during the session, and then transfer to my EMR note within 24 hours after the session.” –Melissa Mitri RD, owner of Melissa Mitri Nutrition
Another consideration for client notes: dictation
If it isn’t a good fit for you and your practice to complete client charts during the visit, you may find that you have a lot to catch up on after the appointment.
If you think more clearly or quickly out loud than when you’re typing, one option to consider is dictating your notes. You may find that dictating any remaining information after your client visits is a time saving option for you.
Now that your note is complete, are there any more steps? You might consider giving a summary to your client.
Do you give a summary to your client?
We recommend that you summarize the visit and goals for the client during your session. This can be done verbally or in written form, depending on your preferences.
What should I include in my summary?
- The date of the visit
- The specific goals set
- Any resources to help achieve the goals
- The reward for achieving the goals
- Date and time of the next appointment
Your client will know exactly what they’re working on between this visit and the next one and have all of the related resources in one place.
Practice Pearl: save time with templates and worksheets. Our blog post Goal-Setting Worksheets Your Clients Will Absolutely Love (and Use!) has a plethora of options to match your exact business goals.
Do you send a note to the physician after the visit?
Keeping in close communication with any referral partners helps to show your value as a fellow healthcare practitioner and keeps you top of mind for the next referral.
Make sure to have written permission from your client to share a summary with their physician or other referring professional. Then, after each visit you need to send a summary sheet.
This is very helpful information when it comes time to follow up and discuss progress with a physician. It also helps if they have any questions about what’s going on, or why something was prescribed.
Keep in mind that physicians are very busy, so brief is best! The Private Practice Resource Kit is a bargain product that includes a physician note template.
New physician? Give them a branded referral form to make getting new clients easier.
Practice pearl: skip buying a fax machine. Get RingRx instead, an app that lets you send and accept HIPAA compliant faxes. Learn more about that and other apps on our blog post: The 28 Best Apps for Dietitians to Use in Their Business.
What if I get audited?
If you are ever audited, the summary report can be used as a quick reference to jog your memory. It’s important that you have accurate notes of everything discussed with the client during the visit.
This will make it much easier for an audit and prevent any inaccuracies from happening in your documentation.
If you are concerned about audits because of the kind of clients you see or your work setting, you can be better informed of your local rules and regulations by joining forums such as The Insurance Credentialing Group for Dietitians and the MNT provider Newsletter. Each state also has its own reimbursement rep to ask questions.
How to brush up on charting skills after taking a break or getting started in counseling?
If you’re feeling rusty because you have taken a break from private practice or are just getting started, don’t worry: you can create a charting system that works for you and your practice!
Just like there are many unique approaches to practicing as a registered dietician, there are just as many ways to chart. If you are starting your own private practice – congratulations – you get to try a few different methods and figure out what works best for you.
If you’re joining a practice that has an established system, don’t worry! Even if you haven’t done the exact charting format or used the exact EHR that they’re using at the practice you’re joining, you can learn. Many facilities will have you shadow other RDs to learn the ropes, including charting before you’re on your own.
Key takeaways: Charting Tips for Dietitians
Client charts are important documents to keep. Using a template and customizing it to your specific niche and preferences saves you time! Focus on checkboxes and drop-down menus
The Charting Template Bundle saves you time getting set up with your practice and each time you visit with a patient.
Get as much done before and during the client session as possible so that you’re not stuck with a bunch of work to catch up at the end of the day. Be sure to be in good communication with your client after the session with a summary of the session and goals as well as their referring physician.
And as soon as you have a new form, handout or template that can benefit your fellow dietitian entrepreneurs, be sure to set up your own shop on RD2RD. It is fast, easy and helps you to achieve your income goals more quickly!