Streamline Your Follow-up Session Charting - From Overwhelmed to Awesome
Scenario #1…. You just got your MS degree in Nutrition and you have a few clients. You are already behind in charting. You just can’t keep up with your nutritionist soap note. You love creating the recommendations and doing the detective work but you are totally lost and don’t have a system for documenting your cases. How much do you write down? Do you have to keep a note for each visit?!?
Scenario #2…. You learned charting in your MS degree but feel like it is soooo detailed and in order to keep your notes up-to-date you need to spend hours and hours. You will never be able to run a successful and profitable business at this rate!!
Patient documentation is very important for your practice. Your charting notes are a legal document. And for CNS Supervised Practice Experience you need to document each case and consult. Start getting into good habits NOW so you have the muscle memory for documentation for years to come.
Here are 3 key tips for staying organized with your charting notes and nutritionist soap notes at any phase of their practice!
1) Type your notes while you listen and speak.
I love phone and zoom because you can type and document so easily while you meet with the client. You are looking at the computer already. It may be messy but getting it down now you can clean it up after. The sooner we document the more accurate our notes will be.
There are simple ways to keep an electronic health record as a nutritionist and we go over this in our Nutritionist’s Playbook course that is part of our CNS Supervision and Mentorship Program.
2) Duplicate the past SOAP or charting note rather than start from scratch!
Don’t start from scratch for each charting note. Instead duplicate the last SOAP note and tweak and modify it! Overwrite what has changed. Keep what has not changed. This is a game changer for me in my practice.
For instance, the family medical history is not likely to change. The labs you noted and analyzed from 2-months ago have not changed. Their diet may likely change and you can take a new 24 hour recall or food diary summary in your notes.
In our CNS Supervision & Mentorship Program, we set up our CNS candidates and new nutritionists with legal and intake forms through Google, Practice Better or Healthie. Each of these electronic health records has strategies for easier charting and documentation.
Practice Better - you can duplicate a charting note and edit that one. You can also set up templates for use
Healthie - you can autofill forms from previous notes. This is my EHR and I love this feature.
Google drive - you can keep a new google doc for each case note. Just copy the last one and update title and date of the note.
Interns can learn how to document their follow-up notes in our teaching clinic. This is a great opportunity for interns to shadow and observe our CNS supervisors with live clients, interview and document cases.
3) Use concise language like phrases and bullet points not sentences!
For instance, a client tells you about their sick pet, traveling etc. They did not implement changes yet. This may be a 5 to 10 min conversation. But all you need to document is “Nutrition recommendations not implemented at this time.” You can certainly note elements of narrative to be able to remember personal details of life to circle back on later.
Want to learn more about charting, check out our Vlog post on SOAP vs ADIME notes.
Are you a CNS candidate working to complete the 1,000 hours and get board certified? Check out our Vlog post on staying on top of your hour documentation and paperwork.
Rebecca Snow is a CNS Supervisor, Mentor, Business Owner, Nutritionist and Herbalist! She has been practicing for over 20 years and mentoring for over 10 years. She loves helping new nutritionists build confidence and take their practice from overwhelmed to thriving!!
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