Nutrition charting to document client interactions is an important and integral part of workflow when providing nutritional care. Unfortunately, our providers report typically spending 40% of their work-day on back-office administrative work like charting and billing. This is time NOT being spent on client care, and is also not compensated time. Moreover, if client sessions are scheduled back-to-back, providers spend time at the end of their workday to go back and finish chart notes, which is time-consuming, and can lead to errors.
Having an effective charting system will:
- Save hours of time, per provider, each week – especially if clients are scheduled back-to-back
- Increase accuracy and consistency in documentation within a client’s record
- Prevent needing to go back after a session, or at the end of a work day, to make updates
If you are currently using a combination of paper forms, Word Files,Google Drive files for your charting, it’s time to make the switch to an online, secure charting platform. An online platform will allow you to efficiently write new chart notes, host client information, and refer back to prior chart notes, all with a few clicks. You’ll be able to access chart notes securely, from any device, at any time. Plus, you can let your clients know that their information is being held securely, using a HIPAA-compliant platform.
Within an online charting platform, you’ll also be able to request, complete and store:
- Intake paperwork
- Signed policy forms
- Chart notes organized and automatically archived from every session
- Lab reports or other digital documents
- Notes received from other healthcare providers via E-faxing
Here are 5 ways Healthie helps you save time on client charting:
1. Create charting templates that are designed for the type of care you provide
As part of your platform set up, think through the way in which you’d like to take notes. By having pre-created, easy to fill out chart notes, you can significantly cut down on the amount of time it takes to finish charting. Healthie hosts industry standard templates like ADIME and SOAP notes and Free Text forms, or you can customize your own charting templates using the Healthie Form Builder. Create your own template for different appointment types (ie. initial sessions and follow-up sessions) and for different clients groups you may be working with (ie. a follow-up template tailored for a weight loss client, and another follow-up template for eating disorder clients). By customizing your charting templates, you’ll be able to use it as an outline for your session that accommodates your counseling approach, techniques, methods and clientele. If you work with insurance-based clients, you may also want to customize your charting forms to ensure that you capture necessary information for billing purposes.
Part of a health coaching program? Email us firstname.lastname@example.org as we have charting templates and practice forms that can be uploaded directly to your Healthie account for you to use with your clients. If you already have existing forms for your practice, our team can also assist you by creating them within the platform.
2. Require clients to send new client paperwork prior to your initial session
Requiring clients to fill out new client assessment forms prior to your first session is a highly effective way to obtain relevant charting information. Within Healthie, you can create an intake flow (series of forms and policies for clients to fill out electronically and e-sign). If you work with different groups of clients, you can create a unique intake flow to be associated with each group. Returning to the example of working with weight loss clients and eating disorder clients, you can create a customized nutrition assessment form tailored for each group.
When you add a new client to Healthie, you can select the group and intake flow you’d like the client to be associated with. Your new client will automatically receive the right nutrition assessment form, and be prompted to complete their paperwork in advance. All clients forms are securely stored within their profile, which you can view as their healthcare provider.
Prior to an initial consult, you can review your clients paperwork and leverage the information provided to pre-fill a portion of your initial chart note. During your session, you can verify the information and elaborate on your client’s report of info, saving a significant amount of time spent charting post-session.
Some practices will even create their own follow-up forms for clients to complete prior to each follow-up session. You can prompt your clients to electronically complete the form prior to each session and save it within their Healthie account for you to view. It will give you important insights into your client’s progress, and allow you to grab the information from the form to use in your follow-up chart note.
3. Use the pre-fill feature in Healthie’s form-builder
Minimize the time you spend charting by adding in “smart fields” within your customized Healthie nutrition charting templates. As you chart, smart fields will automatically pre-fill with existing information from your client’s chart. With an improved workflow experience, you can complete your nutrition charting during your client’s session, and eliminate the need to chart afterwards or at the end of your workday.
4. Document during a client session
Charting during a client session is a skill that takes practice, but can be incredibly powerful in decreasing your nutrition charting time. Prior to starting your client session, open up the charting note template that you’ll use, on a computer or tablet device. As you work through your session, jot down your notes as you collect information from your client and leverage Healthie’s smart-fill fields. If your practice offers telehealth sessions, you can also complete your chart notes from the same screen while conducting a video call.
Some best practices for in-session documentation:
- Be upfront with your client at the beginning of the session — let them know you’ll be jotting down some notes on the computer or on your tablet, while you speak.
- Many clients like to take notes during a session, or feel they should be writing information down. Consider offering to send your clients post-session a quick summary of the plan and goals that you’ve typed up in their chart note. They will likely feel more relaxed, and can give you their undivided attention in session.
- Read your client’s body language — if they are speaking about something that is uncomfortable or emotional, it’s best to pause from typing and give them your undivided attention.
5. Add a short buffer of time in between your client sessions
We recommend adding a 15-minute buffer between client sessions. We recommend building a check-list of what you need to accomplish during this time, while your client is still top-of-mind. This checklist can include:
- Wrap up your client’s chart note, while your conversation is still top of mind
- Send a quick post-session summary of your client’s nutrition plan and wellness goals
- Share any additional resources that you discussed, like recipes, guides or meals plans with your client. Within Healthie, you can store these documents within your Healthie Documents library, and share directly with your client (or group of clients)
- E-Fax your chart note to your client’s referring physician
- Generate a CMS-1500 claim or Superbill
In most cases, while you are spreading out client sessions a bit more, it’s far more efficient to have buffer time between sessions, rather than completing these activities for all clients at the end of your work day. For Healthie users, you can set an appointment buffer by visiting your “appointment settings” from within the Calendar portal. Scroll down to “set appointment buffer” and from the drop-down choose the amount of time you want to set.