Effective clinical documentation is crucial for dietitians, especially when managing conditions like coeliac disease. A well-structured document ensures clear communication between healthcare providers and supports patient care continuity. In this guide, we'll explore how to write and format a dietitian's letter for a coeliac disease patient, using our template and example as a reference.

Introduction

Begin by addressing the referring physician and stating the purpose of the referral. For instance:

Dear Dr. Smith,

Thank you for referring Emily Johnson, a 32-year-old, for dietary assessment and management of coeliac disease.

Patient Symptoms and Investigation Findings

Detail the patient's symptoms and results of any investigations conducted. This provides a comprehensive view of the patient's current health status.

Emily describes experiencing frequent abdominal pain, bloating, and diarrhea, which prompted her visit. I note her investigations to date have shown positive serology for coeliac disease and villous atrophy on gastroscopy.

Medical History and Current Medications

Include any significant medical history and medications, if applicable. This section helps in understanding the patient's health background.

Medical History: No significant past medical history.

Medications: None.

Anthropometry and Dietary Assessment

Provide current anthropometry data like BMI and results from dietary assessments. This information is vital for diet management and progress tracking.

Anthropometry: BMI 22.5 kg/m².

Emily has adopted a gluten-free diet for the last 3 months. A diet assessment today identified traces of gluten in Emily's diet, likely due to cross-contamination.

Consultation Details and Recommendations

Outline the details of the consultation, including educational points and dietary recommendations. This section is critical for guiding the patient's dietary management.

Therefore, in today's consultation, I have provided education on a strict gluten-free diet as treatment for coeliac disease. We discussed gluten-free alternatives and food products, label reading to identify gluten-containing or gluten-free products, and strategies to minimize cross-contamination during meal preparation or when dining out. Nutrition resources including suggested meal ideas, a shopping guide, recipes, and gluten-free cookbooks have been provided to assist with long-term compliance. I have encouraged membership with Coeliac Australia to keep abreast with the ever-changing nutrition information.

Nutritional Adequacy and Follow-Up

Address any nutritional deficiencies and plan for follow-up consultations. This ensures ongoing care and dietary adjustments as needed.

Finally, we briefly discussed optimizing nutritional adequacy, particularly for iron and calcium, by incorporating fortified foods and supplements. A multi-vitamin and calcium supplement has been recommended.

Emily will return for a follow-up appointment in 6 weeks for further dietary modifications. We may also consider additional nutritional strategies. I look forward to working closely with you. Please do not hesitate to contact me if you require any further information.

Yours sincerely,

Dr. Thomas Kelly

The documentation process can be time-consuming, taking away valuable time from patient interactions. This is where AI medical scribes like Notis AI Medical Scribe come into play, revolutionizing how dietitians document patient interactions.

Streamlining Documentation with Notis AI

Notis is an advanced AI-powered medical scribe that significantly reduces the time spent on documentation. It leverages voice-to-text technology to transcribe patient interactions into structured SOAP (Subjective, Objective, Assessment, Plan) notes. This automation allows dietitians to focus more on patient care, with users saving up to 2 hours per day on administrative tasks.

Key Benefits for Dietitians

Notis enhances productivity through its seamless integration with WhatsApp, requiring no additional software. Its high accuracy in transcribing medical notes ensures reliable documentation, and its multilingual support caters to a diverse patient population.

By implementing Notis AI Medical Scribe, dietitians can enhance their documentation process, ensuring comprehensive and accurate patient records while dedicating more time to personalized patient care.