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The Dietitian Who Hates Charting

By Geneviève Marchand, RD
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(Read the original French version of this article.)

I don’t think I need to explain to you the importance of good charting. As fellow dietitians, you’re probably aware of how our notes can be a reflection of our professional expertise. You’re certainly also aware that it’s an important tool for interprofessional communication and necessary for legal protection. However,  charting done properly can be time consuming, tedious and requires a lot of energy. At least, it does for me!


A lot of time and a million questions

I’ve been a Registered Dietitian for 3 years. And, to be honest, even though I know the importance of good record keeping, I hate this part of my job. I remember the hours I spent in the evening finishing my notes and racking my brains: Did I include enough details? Did I put in too much? Will someone else understand my notes? So much time and effort just to do my job properly! And I know from talking to my colleagues that I’m not the only one in this situation.

Several dietitians and nutritionists at TeamNutrition, a group of private practice RDs based in Canada, have also experienced this problem.  To resolve it, we developed an electronic charting system to streamline the process for the entire profession. This system, accessible on any computer with an internet connection, contains our patient records, as well as templates for assessment and follow-up notes. The evaluation questions included in our system were designed and structured by dietitians to best meet the needs of our teams. There is also a section for filing documents provided by the client, such as laboratory data.  In support of the profession of dietetics, TeamNutrition has decided to share our  electronic charting system with DC members at no charge. This system offers many advantages for dietitians and nutritionists like me and you, who want to save time without sacrificing rigor or professionalism.

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PES: a puzzle

The nutritional diagnosis (or if you’re like me, you might remember it as a PES statement - Problem related to Etiology as evidenced by Symptoms) is the most important element of a dietitian’s note, but also the most headache-inducing! Although the diagnosis is what determines our plan of action, it’s not always easy to identify each PES element and present it in a way that’s clear and easy to understand for other healthcare  professionals.

To solve this problem, our electronic charting system contains pre-established PES statements in a drop-down list that were determined by dietitians on our team (including myself) and based on PES statements found in the International Dietetics Nutrition Terminology (IDNT) reference manual. This system has saved me a huge amount of time and has standardized my diagnoses, which gives my work a much more professional image and makes my nutritional treatment plan easy for other healthcare professionals to follow.

These PES statements also allow us to better identify possible issues for cases that we are less comfortable with as a professional. I recently created a continuing education course on bariatric surgery, Introduction à la chirurgie bariatrique - Types, complications et interventions alimentaires (available on Learning on Demand in French) based on my experience with one of the types of clients that I sometimes see in the clinic and whose records are often time-consuming. I can tell you that this system has literally changed my life at work by simultaneously reducing my workload and making my notes much more rigorous when charting for both my bariatric clients and all my other clients.  

The other good news? We’re still actively working on the development of new PES statements to better equip dietitians with more tools under their belt!




Other features that keep me stress-free

Our system also has other advantages that have helped relieve my professional stress: the records are on a secure external server, ensuring that sensitive data is protected. What’s more, everything is automatically saved in the system, so you never have to worry about losing all your notes!

Our electronic charting  system has been incredibly useful in my professional life, keeping my notes organized, complete and professional, while also keeping the hassle of charting to a minimum.

How to access it for free

Made by dietitians for dietitians, we are committed to support the work of our fellow colleagues and the growth of our wonderful profession.  TeamNutrition (EquipeNutrition) would like to offer the use of this system free for DC members. If you too want to lighten your load, simply write to us through our form on our contact us page. We will then be able to create your account to help you in your practice. Exclusively available only to Dietitians of Canada members.



 

Geneviève Marchand has been a Registered Dietitian in a private clinic for several years in Quebec within the TeamNutrition network and a member of the Ordre professionnel des diététistes du Québec (OPDQ). She graduated from Laval University with a Bachelor's in Nutrition and a Master's in Nutrition. Passionate about evidence-based practice, Geneviève is always looking for ways to update her knowledge. With the profession of nutrition and dietetics near and dear to her heart, she plays an active role in shaping the field by writing evidenced-based articles on hot topics in nutrition, sending newsletters to other health professionals, and developing new clinical tools to support fellow dietitians. In her personal life, Geneviève loves exploring the outdoors and cooking, and is passionate about eating locally and sustainably.


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