Keeping accurate health care charts is essential for any nutrition private practice. While you want to have a conversation with your client that flows naturally, you also want to keep a professional and organized record. Leveraging health care charting templates can help make your record keeping easy, optimize your time and ensure that you’re capturing important client information.
Here are a few reasons you may want to use health care charting templates:
1. Better direct your conversation with your clients
Charting templates can be used as an outline for your conversation with your clients. After helping several clients, you will have a better idea of the questions and motivational interviewing prompts to use to gather the information you need.
2. Concisely record the information you need to know
Nutrition charting templates prevent you from acting as a scribe. It may seem easier to scribble everything down when your clients are speaking, but a template helps you extract the essential information.
3. Maintain better records for insurance, physician referrals, and yourself
Formal health care charts are not always necessary, however, thorough charting makes it easier for you to submit insurance claims, communicate with referring providers, and jog your memory if its been a few weeks since you last saw your client.
4. Charting is required for insurance-based nutrition practices
If you accept insurance in your nutrition practice, keeping diligent health care charts is essential. In the case of an insurance-audit, your chart notes will be reviewed and analyzed. Utilizing a charting template will ensure consistency in your charting for across clients and always ensure you’re documenting pertinent client information. This will protect both you, and your business.
Now that you understand why health care charting templates are so important for your private practice, here is some information you may want to gather while taking notes.
Charting for Initial Nutrition Consultations
Charting for your initial nutrition consultation is likely more detailed than for follow-up nutrition visits. It is essential to get a well-rounded picture of your client’s health and health/diet history.
You can get as detailed as you’d like, but we suggest including the following information in your initial nutrition charting templates:
- Reason for visit and nutrition goals
- Diet history
- Health history
- Weight and recent weight changes
- Current vitamins, supplements, and medications
- Food allergies and restrictions
- Current diet and lifestyle
- Next steps or plan of care
- Follow-up scheduled?
- Nutrition History
- Next steps
Charting for Follow-up Nutrition Sessions
Since you already have a well-rounded picture of your client’s current and past health, your follow up charting template can be a bit simpler.
We suggest including some (or all) of the following in your follow up nutrition charting templates:
- Progress since last visit
- Weight change
- Comments on food log & health profile
- Goals moving forward
- New Goals
Good nutrition charting is essential for communicating your plan of care to other healthcare professionals. Health care charting is considered a legal document. It provides proof that you gave your client the highest standard of care. The key to good charting practices is in recording the information while it is fresh in your memory. Strive to be concise and be accurate!
All Healthie members have access to Healthie’s extensive library of nutrition charting templates, including specific templates for various coaching programs.