Nutritional care providers are required to complete detailed charting records for every client session. Specific charting notes are helpful to document a detailed care plan, evaluate care goals and outcomes, share notes with other providers, transfer records in the future, maintain client records in case of an insurance claim audit, and more.
Did you know that charts are confidential legal documents? Thorough documentation of an encounter with a client is often required for insurance reimbursement claims and physician referrals – plus quality control management. This can include documentation of client history, short- and long-term goals, and specific diagnosis codes.
For busy providers, writing notes from scratch can be time-consuming, inefficient, and require substantial typing during and after each client session. Thankfully, there’s a more efficient way to chart.
Introducing Customizable Charting Templates
Healthie’s customizable charting templates are designed specifically for dietitians, nutritionists, and other healthcare professionals. Because these charting templates are customizable, they meet each practitioner’s specific workflow needs. Healthie’s built-in templates include ADIME, SOAP notes, free-text, and intake forms. Other EHR platforms are generally tailored to doctors and other medical professionals, making it cumbersome for nutrition professionals to navigate. By creating your own templates, tailored to your clientele, it will allow you to capture nutritionally relevant information in a much more streamlined manner.
Healthie charting templates can also be specialty-specific – including general wellness, eating disorders, diabetes management, functional nutrition, and more. Plus, Healthie’s charting templates are effective across all practice sizes.
Note: There may be specific nuances required for a particular insurance company, ICD-10, insurance company, state regulation, and more.
Healthie is also introducing the ability for practices to share their customizable charting templates with other providers. Through a joint library, providers will be able to leverage best practices and reduce the time spent “recreating the wheel.”
Charting templates significantly reduce time spent charting during and after a client session, and increase the flow of information between providers.
How To Utilize Charting Templates in Healthie
Building out your own charting templates is easy with Healthie’s Form Builder. Utilizing a “drag-and-drop” feature, you can utilize the question bank to drag different information fields onto your charting form. Edit any field to further customize your questions. Healthie’s question bank includes a number of pre-created questions that nutrition professionals typically ask of clients, but there are also many basic question fields to choose from.
Using Healthie’s form builder, you can quickly customize a charting template to collect:
- Basic client information + demographics
- Medical history + medications
- Vitamin/supplement usage
- Nutritional history
- Weight history
- Diet recall
Charting templates can also easily be turned into an “intake form” that is automatically distributed to clients as part of their new client intake paperwork. Clients can electronically fill out “pre-assessment” paperwork and providers can view this form at any time by pulling of the client chart within Healthie.
Access these resources to learn more about how you can tailor your charting notes, utilizing Healthie’s EHR platform.