How to Use EHR Systems

Learn about how to use EHR systems to chart wellness clients. Discover the best way to organize paperwork and client information at Healthie.

For an efficient, streamlined health and wellness business, having a quick, easy, and organized way to document client interactions is invaluable. Healthie offers the online charting for nutritionists so that providers are able to transition away from paper charting, Google Drive Documents, and Word files, and into a cohesive, simple, and modern way to securely chart on clients during and after sessions.

Healthie’s e-charting platform is comprehensive and enables providers keep charting notes in accordance with healthcare recommendations (many providers are required to keep chart notes for 6 years – having this in paper files can quickly become overwhelming!), while avoiding the clunky feel of traditional EHR charting systems in hospitals (because no one wants to spend their hours with unneeded clicks and drop downs). Healthie’s HIPAA-compliant charting system is a sophisticated online system that keeps your clients’ information secure, organized and easily accessible. Each client has an online profile that includes a secure archive of previous chart notes on sessions, intake forms, and private documents, that can even be e-faxed directly within the system for coordination across providers.

Healthie’s charting system for nutritionists can include the following elements:

  • Intake paperwork
  • Signed policy forms
  • Chart notes organized and automatically archived from every session
  • Lab reports or other digital documents
  • E-Faxing capabilities to share client information with other healthcare providers
  • Shared access for members of an organization, with admin controlled permissions on who can access client information

With a foundation and focus for building electronic health record (EHR) templates for health, wellness, and nutrition, Healthie’s templates and workflows are designed for collection of needed information, and are tied to healthcare metrics (weight, BMI, Mifflin St. Jour, as just three examples), with as few clicks as possible.

In this article, we’ll provide an overview of how to customize the Healthie EHR and charting feature to meet your business’s specific needs, along with best practices we see on how to streamline charting processes when you work with clients. From charting during a session, to post-session edits, to quick billing and insurance claims, we’ll show you how to improve workflow from start-to-end within the Healthie platform.

Healthie’s Charting for Nutritionists: Quick Access to Important Client Information

Save time searching and organizing your clients’ information, with one-click access into their secure Healthie client chart. From your clients’ charting tab, your paperwork is easily accessible and organized in a way that makes sense for nutritionists.

  • Private chart notes: not visible to clients unless requested
  • Client’s intake paperwork: revisit your client’s initial intake and assessment forms
  • Documents: viewable by your client, you can share educational resources, lab results, exam results and other documents, directly to your client’s chart for them to access at any time
  • Private documents: store any important information on your client (like chart notes and assessments from other healthcare providers, hospital discharge forms, etc)
  • Request form completion: automatically prompt clients to fill out any important new client documents and policies (intake forms) to be digitally completed and automatically stored to their chart
  • Download a client’s summary: with one click, download a digital overview of your client’s information, to print or share with other healthcare providers as needed (or E-Fax individual paperwork or chart notes)

Benefits of Using Charting for Nutritionists:

Designed with dietitians and nutrition professionals in mind, the Healthie EHR and integrated billing platform allows you to improve workflow through a number of processes.

1. Securely access your clients’ information from anywhere

Login to your Healthie provider account from anywhere, and from any desktop or mobile device. Securely access your entire business, including your clients’ information, on the go, providing you with flexibility. No longer have to run back to the office, dig through paperwork and emails or login to multiple digital tools to find the information you need.

From your client’s Healthie profile, you’ll be able to access all of their chart notes, documents, financials, billing history and see past or upcoming appointments — without ever putting your client’s private health information at risk.

2. Streamline your charting, with Healthie’s pre-created charting templates designed for nutritionists

With dietitian, nutritionists, health coaches, and other wellness professionals in mind, we have pre-built charting templates that you can leverage in your business, and further customize to meet your business’s specific needs. Plus, e-sign your chart notes after each session by adding an “e-signature” button to your templates.

  • ADIME notes: most commonly used by dietitians, ADIME notes are structured to document your “assessment, diagnosis, intervention, monitoring, evaluation strategies,” for a consistent format of documentation supported by the Academy of Nutrition and Dietetics.
  • SOAP notes: designed to document your subjective information, objective information, assessment and plan for each client interaction
  • Free-text: for quick notes on a client, free-text style notes allow you to follow a non-structured approach to documentation, primarily used with non-clinical clients.

3. Create your own customized chart notes with Healthie form builder

Create your own nutritional charting templates through the Healthie form builder. With a user-friendly, drag-and-drop style, you can easily drag + edit long or short-answer questions. Even more, create a check off, drop down or multiple choice questions to streamline how you chart on clients during follow-ups. Include an e-signature block to professionally sign-off on your notes after each session. By having pre-created, easy to fill out chart notes, you can complete your charting in minutes or even during your client session, leaving you more time to focus on other important business tasks (or see more clients!).

4. Use “smart fields” in form builder to quick-fill chart notes

Minimize the time you spend charting by adding in “smart fields” within your customized charting templates. As you chart, smart fields will automatically pre-fill with existing information from your client’s chart. With an improved workflow experience, you can complete your charting during your client’s session, and eliminate the need to chart afterwards or at the end of your workday.

5. Build your existing charting templates into the platform

Have a specific way that you chart on your clients? Work in a group practice and want to have one uniform and specific way to flow through client follow-up appointments? Healthie can import or build your existing forms directly into your Healthie account for you, and you can share forms with colleagues to save everyone time.

6. Automatically bill clients or generate CMS-1500 claims and Superbills

Request a payment at the end of a session or create a payment package with recurring auto-payments. For insurance-based practices, at the end of each chart note you can quickly auto-generate a CMS-1500 claim, which auto-fills information from your organization information and client profile. For out-of-network clients, they may still be able to receive reimbursement or credit towards a health or flex spending account by submitting a Superbill to their insurance provider.

Best Practices for E-Charting Within a Nutritionist EHR

1. Build 2-3 templates that you will use in your care

Charting templates can be used for initial sessions, follow-up sessions or even group meetings. Whether you’re a seasoned dietitian or newer practitioner, having your charting templates ready from the onset will help you minimize the time that you spend charting during or after client sessions. From initial consult to follow-up sessions, you’ll easily be able to provide seamless care with high quality documentation.

2. Using E-Charting to structure follow-up sessions

Think of your charting templates as an outline of how you’ll conduct each client session. Your template gives you a flow to structure your sessions, and prompts you to collect all relevant information. Your charting templates are especially helpful in keeping you in control of the direction of conversation, and timeliness of your sessions.

For organizations and group practices, having structured charting templates ensures consistency in documentation across your providers. Easily onboard new providers and feel confident that they are structuring their client sessions according to your business best practices. It will also ensure that each provider is documenting important information that you may require for billing or insurance purposes. As an administrator on the account, you’ll maintain permissions on provider accounts, allowing you to have oversight of your team.

3. Create charting templates that best fit your client(s) needs

Depending on your client population, you may want to structure your charting templates to capture more or less information.

For example, if you work with eating disorder clients and process claims through insurance, you may want to have an incredibly detailed follow-up charting template. This will ensure that you’re capturing all of the information required for reimbursement. In contrast, if you work with self-pay clients that don’t have any complex medical issues, you may want to have a short and concise follow-up charting template for ease of documentation.

Create as many charting templates as you’d like, with all of your client groups in mind. When you click into a client’s chart, you’ll see a drop-down menu that includes standard charting templates, along with every custom template you’ve created. Quickly select the appropriate template for that client, and start documenting!

4. Improve workflow with pre-fill features

We cannot emphasize enough the power of using pre-fill questions in your Healthie charting templates. When you use a “smart field,” within your template, you’ll easily save time spent documenting, not only for that client, but every client. This is especially important as you scale and grow your practice. As you work with more clients and groups of clients, the time spent documenting will allow you to focus on other important business efforts like marketing a new program.

For Healthie Members: here’s our list of resources to support your nutrition practice on the Healthie platform

Overview: Charting

Charting templates available in Healthie

Enable “pre-fill” on chart notes

Switching a charting template to an intake form

Charging a client or requesting payment

Documents within a client’s chart notes

Edit a previous chart note

Sharing a chart note with a client

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