Optional Reading: Chart Note Structure

Much of the information within the Initial Session chart note will be pre-populated from the patient's intake form. Review and supplement, as needed.

If a patient is transferring their care to Nourish from another platform in which the RD was previously seeing them, a comprehensive nutrition assessment must be documented.

1. Chief Motivation: Capture the patient’s core motivation for seeking care - their “why.” This might include personal goals, health concerns, or meaningful life changes they hope to achieve through nutrition support.

1. Conditions: Confirm or update the patient’s primary and secondary conditions. Be sure to check the confirmation box - this is required to sign the note.
   Please view the “Managing Patient Conditions in Chart Note” article for additional guidance.

2. Personal & Family Medical History: Review and edit intake form responses as needed. Enclose retained patient-written text in quotation marks.
   Focus on relevant clinical history; labs, lifestyle, and meds are addressed later.

3. Height, Weight, and BMI: Record height and weight during the initial session; BMI will be calculated automatically. Update weight as needed and record any relevant weight history and context (e.g., recent changes, history of dieting) if clinically relevant.

4. Labs & Progress: To add a new lab or test entry, select Add labs or progress and a pop-up modal will appear. To see historical labs & progress questionnaires, select the clock icon next to the header of the section.

5. Medications: Add medications from a dropdown list gathered from the National Library of Medicine at the National Institute of Health (nlm.nih.gov).

   • You will need to find the medication by typing in the Name field, then add the relevant Dosage, Frequency, Start date, and End date (if the patient is no longer taking the medication), before selecting Save changes.

     • After saving, you will be able to edit the end date of the medication by selecting the three dots next to the medication, selecting Edit end date, and changing to the relevant date.

     • If you need to change frequency or dosage, you should re-add the same medication or supplement again, this time at the different frequency &/or dose.

6. Lifestyle: Summarize lifestyle factors and intake screen responses that impact care.

7. Diet Recall: Record a recent diet history for the patient. Import patient meal log data from the Nourish app by selecting Import Logs.

8. Diagnoses: Nourish documents diagnoses using PES (Problem, Etiology, Signs/Symptoms) statements, a standardized format used in the Nutrition Care Process. Selections are from the 2024 eNCPT (electronic Nutrition Care Process Terminology) standardized language for the PES statement.

   • To add a new PES, select Add new within the section.

     • The Problem list is single select and and cannot be edited after the individual PES is saved.

     • The Etiology list is a dropdown based on your selection for Problem. It can be edited later but will be locked for the current note once signed.

     • The Signs & Symptoms are multi-select based on a category, and should include additional context in the “More details” field to describe the specific patient situation. These can also be edited in future notes but are locked once the note is signed.

   • You can mark a diagnosis as resolved (via the three-dot menu), or delete it if no longer relevant, though deletion should be rare. Past PES statements will still be viewable in historical notes.

   • Ensure inclusion of supporting evidence for your PES statement. For example:

     • If using “Lab work and tests – abnormal or worsening” as a sign/symptom, include specific lab values in the chart.

     • If using “Maladaptive eating patterns,” document which behaviors you're referencing.

   • A PES statement is expected in most chart notes, especially when follow-ups are scheduled or interventions are in progress. However, a PES statement may not be necessary in the following situations. These exceptions should be clearly documented in the chart to ensure accurate and complete records.

     • The patient's nutrition problems have been resolved, and they are transitioning to a maintenance cadence or pausing Nourish care.

     • During an initial assessment, no nutrition problems are identified, and no follow-up appointments are planned.

9. Interventions: Document what you did in-session to resolve the nutrition diagnosis (PES). There are four possible intervention categories, and you can select more than one. After selecting, add details to the intervention(s) as shown below. (See attached pdf at bottom for sample interventions.) Intervention Details should not speak directly to the patient or simply be a list of short term goals, but rather focus on what the Dietitian provided to the patient in session.

1. Long-term goals: Long-term goals are internally-facing outcomes to guide care across sessions and should align with the PES and intervention(s). These goals are not visible to the patient. Examples of long term goals include: Improved lab value, Gradual weight loss, or Improved relationship with food or body.

2. Short-term goals: Short-term goals are patient-facing actions outlining how the patient will apply the nutrition interventions between now and the next follow-up session. Short-term goals can be edited and marked complete by both patients and dietitians. Short-term goals should align with the PES and intervention(s).

3. Set macro goals (if applicable): Enter appropriate energy needs by calculating macronutrient ranges for your patients.
   See the Calculating Energy Needs & Macros for Patients article for additional guidance.

1. Follow-up plan: Best practice is to schedule at least 4 weekly, recurring appointments in the initial session to maintain momentum and reinforce behavior change. Leverage the built-in scheduling tool at the bottom of the chart note.
   This will open a new tab to the calendar and will be prefilled to include 4 recurring, weekly sessions from the initial session. In follow ups, if the patient does not have another session booked, the calendar will open to suggest 1 follow up session.

2. Phase for next note: Select the appropriate Phase for your next session with this patient. Please reference the above section on “Phase of Care Navigation” for guidance on when a patient may be ready to move forward in their care journey. Please use your clinical judgment and consider the patient’s unique needs when deciding whether more or less time is needed in the current phase.

1. Appointment Summary: Anything included in the appointment summary box will be e-mailed to the patient once the chart is signed and locked. Use the AI-generated summary as a starting point and personalize as needed. These summaries should speak directly to the patient and include key discussion points and short-term goals covered during the session.

1. Chief Motivation: Record the patient’s main motivations for seeking out care, focusing on their goals and motivations.

2. Patient Update: Only include what was discussed in this specific session. It does not need to be exhaustive, rather, should be a short summary of key topics.

   • If there are updates to any of the patient's medical history, lifestyle, labs & tests, or anything else from the Assessment & Diagnosis, they should be made directly in those questions.

   • Previous patient updates can be viewed by selecting View all. Given the historical storing, do not leave past patient updates within the note.

3. Diet Recall: Record a recent diet history for the patient. If helpful, view past diet recalls by selecting View all. Select Import Logs to import patient meal log data from the Nourish app.

1. Height, Weight, and BMI: Update weight as needed and weight history as appropriate.

2. Labs and Progress: Add a new lab or test entry as available and relevant to care. To see historical labs & progress questionnaires, select the clock icon next to the header of the section.

3. Medications: Add or edit medications as relevant to maintain a full picture of patient condition.

4. Conditions, Personal & Family Medical History, Lifestyle Assessment: Update as relevant or as new information is gathered.

1. PES statements: Revisit as relevant or as new information is gathered.

2. Interventions: Document what you did to resolve the nutrition diagnosis (PES). Nutrition interventions should directly address the nutrition diagnosis (PES). Intervention Details should not speak directly to the patient or simply be a list of short term goals, but rather focus on what the Dietitian provided to the patient in session.

1. Revisit and edit Long-term Goals and Macro Goals fields as relevant or as new information is gathered.

2. Short-term goals: Revise and realign short term goals to patient’s evolving action plan. Short-term goals should outline how the patient will apply the nutrition interventions between now and the next follow-up session. Short-term goals are visible to the patient and can be edited and marked complete by both patients and dietitians. Short-term goals should align with the PES and intervention(s).

1. Follow-up Plan: Indicate when you plan to see the patient next. Best practice is to schedule at least 3-4 appointments booked out to maintain momentum and reinforce behavior change.

2. Phase for next note: Indicate whether patient should remain within current phase of care, or if patient is ready to move to next phase. Please refer to above guidelines to inform this decision.

1. Appointment Summary: Generate and refine AI summary and email follow-up message.