Progress Notes Are Central To A Nutrition Clinic's Model - Here's Why

Overview on progress notes

Progress notes are a form of clinical documentation that is kept by a wide array of healthcare professionals. Progress notes outline a client's symptoms, treatment, and intervention plans and are often shared between other healthcare providers to ensure an individual receives the best quality of care possible. Research conducted by OpenNotes found that 96% of patients understand the notes written by clinicians; a promising finding as it demonstrates how documentation can improve effective communication between clients and clinicians. A variety of resources have been developed to assist practitioners in maintaining clinical documentation, including formats like SOAP and DAP and digital software that stores progress notes in one secure platform. 

What are progress notes in nutrition?

Just as with any other healthcare profession, nutritionists must maintain their clinical documentation. While this may seem like a time-consuming task, realistically, progress notes do not have to take any more than 10 minutes to write per client. Although all relevant information from each session should be included, a progress note that exceeds two pages would be considered unnecessarily lengthy. The key to writing a practical nutrition progress note is to convey critical information as concisely as possible. 

Following a session with a client, the nutritionist should document the chief complaint and various client symptoms before outlining the intervention plan and future strategies that were discussed. Maintaining clinical documentation in this way will allow the nutritionist to compare a client's progress notes and identify whether the intervention has been successful and any notable improvements or achievements. To increase the accessibility and organization of progress notes, they can be stored on a digital HIPAA-compliant platform specializing in management software for clinical work. 

Importance of nutritional assessment

Assessment is an integral aspect of working as a nutritionist. Nutritional assessment will help identify the presence and type of malnutrition or obesity and develop an intervention plan to target related goals. The nutritional assessment covers a wide range of measurements that will determine the causes and symptoms and point to the necessary treatment options. 

Documenting the results of these nutritional assessments in the form of progress notes will allow nutritionists to evaluate the effectiveness of their intervention programs and make an informed decision about whether an individual's treatment needs to be modified. Improving your clinical record keeping is in your best interest; it will demonstrate your professionalism, increase effective communication, and be a valuable resource in malpractice lawsuits or other disputes. 

What are the four main components of nutritional assessment?

A baseline nutritional assessment can be separated into four general categories; anthropometric, biochemical, clinical, and diet. The specific tests and measurements used to assess each of these parameters will be dependent on the symptoms that the client is presenting and the purpose behind the assessment. Measurements and results from a session with a client should be included in your clinical documentation. The following is a general overview of the measures relating to each parameter: 

Anthropometric: Height, weight, weight change over time, BMI. 

Biochemical: Laboratory measurements of serum protein and micronutrient levels and measurements of hemoglobin, magnesium, cholesterol, and liver enzyme levels.

Clinical: Physical appearance, medications, supplements, and external factors influence an individual's nutritional intake, including social, psychological, and financial issues. 

Diet: Examines the client's diet, including intake of micro-and macronutrients.  

Why are progress notes important for a nutrition clinic?

Writing consistent and effective progress notes has significant benefits for both the client and the nutritionist.

Measurable Improvement: Good documentation is the most innovative tool nutritionists use to measure their client's improvement. Progress notes should include nutritional assessment results, which can be tracked throughout a client's intervention to determine advancement. If the client's condition worsens, the nutritionist will analyze this change and accordingly modify treatment. 

Importance of Communication: An individual who requires nutritional assessment and intervention will often require assistance from either other healthcare providers or family members. Progress notes seamlessly inform third parties of the symptoms, diagnosis, and treatment plan of an individual. For example, a nutritionist assessing a patient in a nursing home may create a treatment plan to encourage weight gain. However, if this isn't documented and the client is kept in hospital for some time, the hospital staff would not maintain the treatment plan, damaging the delivery of care.

Protection: Maintaining good documentation of your sessions with clients can serve to protect you in the unfortunate instance of malpractice lawsuits or disputes. The courts can request progress notes, and if you have adequate documentation, you will be able to defend and justify your professional opinions. You will likely be familiar with the phrase, "If it was not documented, it was not done." Nutritionists must understand the importance of documenting all relevant aspects of sessions with clients, both for the client's benefit and their protection.

Insurance: Accurate documentation is necessary if you accept insurance in your practice; your charts and documents will be analyzed and reviewed if you are audited.

Outpatient dietitian charting template + example

Keeping accurate notes and documentation is an essential part of working at any nutrition practice. While an initial consultation with a client will lead to a more comprehensive note than follow-up sessions, and the topic of the notes might vary, below is a general guideline of the type of information that should be included in nutrition documentation:

1. The reason for visit, including symptoms and complaints
2. Weight and weight changes
3. History of diet
4. Diagnosis or changes in condition since the last session, including improvements and achievements 
5. Nutrition goals
6. A plan for the next session and future treatment goals 

Conclusion

Different resources can be utilized to assist in maintaining adequate clinical documentation, including using digital healthcare software. Carepatron provides practices with a platform to write and securely store their clinical documentation, all according to HIPAA standards. This type of software will ensure your notes are consistent across practitioners and clients and improve efficiency and general organization. 

Maintaining clinical documentation is a critical aspect of working as a nutritionist. Progress notes help ensure that a client receives the best quality of care possible, improves communication with family members and other healthcare providers, and protects the practitioner from potential disputes. 

• Nutrition Care Process and Model