Why is Charting Important?
Documentation
Document assessments, interventions, and outcomes in a structured format. This documentation is crucial for maintaining accurate and comprehensive records of patient care over time
Communication
Charting facilitates communication among healthcare providers involved in a patient's care. Dietitians can easily share their assessments, recommendations, and progress notes with other members of the healthcare team, ensuring continuity of care
Ensure appropriate reimbursement
A well-documented medical record can facilitate effective processes, expedite payment, reduce any “hassles” associated with claims processing, and ensure appropriate reimbursement
Quality improvement
EHR data can be aggregated and analyzed to identify trends, monitor outcomes, and support quality improvement initiatives. RDs and Foodsmart can use this information to evaluate the effectiveness of their interventions and make adjustments as needed towards improved health outcomes
Charting Overview
Our health plan partners require a certain level of standardization of chart notes, which includes Assessment, Diagnosis, Intervention, Monitoring, and Evaluation. Your intervention (which is documented under Assessment/Plan) should ALWAYS include the following components:
Updated and current subjective/patient-reported information
PES statement using standardized terminology
Intervention that attempts to resolve the etiology or lessen the signs/symptoms
Monitoring/evaluation that measures progress of the intervention
Patient instructions that are relevant, specific, and individualized
Patient instructions should be individualized to the patient depending on what you covered in your visit and what you'd like the patient to focus on. Patients report that it is most helpful to receive instructions that are actionable and specific!
Assessment
Your assessment should give another clinician or health plan auditor enough information about the patient to understand what this patient is seeking MNT for. It should aim to answer the following questions:
Why is the patient seeking nutrition care?
What roadblocks or obstacles does that patient report?
What existing symptoms or issues does the patient have/report?
What labs or anthropometrics does the patient report?
What does the patient eat and drink currently?
Diagnosis
Your diagnosis should be written in the form of a PES statement (more on this in the next section) and should communicate the nutrition-related problem that can be improved or resolved by a nutrition intervention.
Intervention
The intervention should aim to improve or resolve the nutrition-related problem from your diagnosis and should include the plan or goal for the client as well as the steps you are going to take to implement the plan.
Make sure that your intervention is client-centered and collaborative, including:
The client
Their needs and values
Options for FoodCare (meal delivery, medically tailored meals, Foodsmart Bucks, etc)
You’ll also want to ensure that the intervention is realistic with the timeline, urgency, and level of follow-up possible.
Monitoring/Evaluation
How will you measure progress on the goals you identified for your client in your intervention? At each follow-up, collect new information and data about the patient to assess how the intervention is impacting the patient and to determine whether changes need to be made to your diagnosis and intervention plan.
Time Documentation
Every single chart note should always include:
Visit Start Time:
Visit End Time:
Total minutes providing MNT:
Units billed should always reflect the time spent providing MNT. Your charting should also back up the number of units billed; chart notes with sparse or limited information and that are billed for 2-4 units will be sent back to the RD for adjustments.
Put yourself in the shoes of...
A health plan auditor: would I read this chart note and understand why 60 minutes of MNT (if billed at 4 units) were warranted?
Another clinician: would I understand what's going on with this patient and be able to conduct a follow-up?
You should answer "yes!" to both of these questions for every single chart note
Using the NCP does not mean that all clients get the same care.