Writing a good nutrition note in a medical record is an important part of a clinical dietitian’s job. My clinical rotation at Meritus Medical Center helped me develop a good format which is easy to write quickly and easy for others to read and understand. Meritus gave their dietitians freedom to use their own style of nutrition note and I was able to work with several dietitians, which allowed me to take aspects from each of them. Here is what I learned about writing good nutrition notes.
Choose a Good Format
To start writing a note, there has to be a solid format. In my experience, using the ADIME (assessment, diagnosis, intervention, monitor & evaluate) format works best. It just organizes the note so that it flows well and gives a good overview of the patient. The SOAP (subjective, objective, assessment, and plan) format can also be used, but since we were taught ADIME in college, I chose to use that format.
Include All Relevant Information
Relevant information for a nutrition note can include patient history, anthropometrics, medications, lab values, and more. Unfortunately, this information is not always in the same place or easy to find. One of the harder parts about learning to write notes was browsing through the EMR (electronic medical record) system for information for my notes. Not all hospitals use the same EMR software, so learning a new system can take some time. Fortunately, my preceptors were able to help me know what information I needed and where I could go to find it.
Avoid Being Too Wordy
When I first started writing notes, they were relatively wordy and in paragraph form. All the necessary information was there, but it took a while to read them. One of my preceptors pointed out that most doctors don’t have time to read a lengthy, wordy note, and that I should condense the note down into bullet points so that anyone reading doesn’t have to skim through a paragraph looking for relevant information.
Finding the Right Balance
By the end of my rotation, I was cranking out notes pretty quickly. My style had developed into a mixture of descriptive sentences and bullet points that I believed were easy to read and follow. I didn’t start out writing great notes, but there was a definite pattern of improvement, both in quality and efficiency, throughout my rotation.