Charting can feel like an enormous task to a new practitioner. There are so many things to juggle. You want to be HIPAA compliant, meet state laws, fulfill the CNS requirements, and organize your thoughts in a cohesive way. You might also be deciding between SOAP or ADIME notes; you can watch this video here for pointers.
Charting is a lot like cooking. The longer you do it the easier it will become. You may start to incorporate new techniques and ingredients as you get more comfortable with the whole process.
Just promise me one thing, please! Don’t forget to write your nutrition assessment. It is the most commonly skipped part of the note. Folks love to jump from gathering data to giving recommendations. You might hear a sign or symptom that reminds you of a supplement and you add that to the recommendations. Skipping the assessment will rob you of the most learning and growth.
Writing your nutrition assessment allows you to prioritize, reorganize and summarize. You can choose the most salient data points to highlight. Your nutrition assessment is the “WHY” of your note. It links the input to the output. It communicates to anyone reading your note (i.e. your supervisor, team member, insurance company or doctor) and justifies your recommendations. Your nutrition assessment allows you to map out interventions that will occur over the course of your work with the client.
Don’t let perfect be the enemy of the good. Dive in and learn how to write an effective and simple nutrition assessment.