These 3 nutrition assessment writing tips for new RDs will keep your assessments concise, easy to write and simple to read.
3 Nutrition Assessment Writing Tips for New RDs
As dietitians, we’re trained to focus on the facts. We learn to read and understand scientific papers. We are encouraged to value peer reviewed journals above all else.
And as a result we are taught to write, document and reference our work in a way that’s reflective of these prestigious articles.
But healthcare writing in the real world is not academic writing.
No one in healthcare wants to read a dissertation on a patient. And as a busy dietitian, you certainly don’t have time to carefully craft one.
This post shows you how to present your patient and the facts of their situation in a way that’s not only clear but concise.
Keep reading for 3 tips that will help you write better nutrition assessments that your preceptors will love and the healthcare team will actually read.
3 tips for better nutrition assessment writing
Here are the 3 golden rules of nutrition assessment writing:
- Keep your sentences short, use only the important words
- Grammar isn’t as important as punctuation
- Abbreviate everything
When writing your nutrition notes, the goal is to keep them as simple and straightforward as possible.
Once you read this, you’ll be able to take the well written sentence:
This patient appears to be malnourished with muscle wasting around their temples and clavicle area. She has lost weight and now has a BMI of 16 after having poor intake since her first admission to the hospital 3 weeks ago when she was first diagnosed with acute kidney failure and is now in need of dialysis.
And turn it into:
Pt with poor intake x 3 weeks since admit 2/2 AKF, now with HD. Malnutrition with BMI of 16, temporal/clavicle muscle wasting noted.
You want to go from that first long sentence to the second short sentence. The shorter your note is, the more likely the healthcare team will read it. And the more clear it is, the more likely they’ll understand it…then follow your recommendations.
Keeping your notes concise will also help you clearly think about the most acute issue and then write stronger PES statements.
When you follow these 3 tips, your nutrition assessment writing will improve immediately.
Keep your sentences short
Short as in, the shorter the better.
And the best place to start making your sentences shorter? Taking out the fluffy words and long-form statements.
Here are some examples that can be considered unnecessary. Once you get your head around these, we’ll move on to how to adjust and write differently.
Transitional sentences, so think:
- As well as
- Therefore
- In addition
- However
Complete statements that describe moments in time in depth like:
- During that time
- Since their second admission that occurred on
- Yesterday, when the patient completed surgery
- After I discussed this with them, I was able to
Individual words that create grammatically correct sentence structure. These are a bit more flexible but good ones to consider removing include:
- This, the, then
- Because
- When
- My, me, I
This is step 1 to better nutrition assessment writing.
Punctuation over grammar
Step 2 does the same thing with your grammar.
Remember, you aren’t writing formal sentences here. You’re writing a string of words that make a very specific point using the smallest number of words.
This is why instead of prioritizing grammar, the focus is on punctuation.
Specifically: commas and periods.
When you’re stuck on how to remove some of those transitional statements, the best place to start is by just adding a comma.
Maybe you want to say:
I saw this patient to do nutrition education on following a cardiac diet as the doctor requested before she is discharged but she has refused to have the conversation today because she doesn’t think it matters.
First, you’re going to take out the unnecessary words and replace them with commas.
Second, you’re going to keep your sentences as short as you can by using periods and creating additional sentences.
This might end up looking like this:
MD requested cardiac diet education prior to discharge. Patient refused, uninterested.
Same concept. Same information. Many less words.
That tip 1 and 2. Now, let’s look at the final step and wrap up your nutrition assessment writing nice and strong.
Abbreviate everything
Abbreviations are one of the easiest ways to shrink a sentence and one of the most effective ways to make your nutrition assessment writing shorter.
Keep in mind, you don’t have to use abbreviations all the time. You can also pick and choose the ones you prefer using.
But whether you love them or hate them, you do want to know them.
Medical abbreviations are not only commonplace, they’re also how you’ll write shorthand nutrition notes quickly.
This handout on clinical nutrition abbreviations is found in the Clinical Resource Bundle and is a great references to get you started.
The goal isn’t to memorize every medical abbreviation. Memorization is never the objective.
Your goal is to know when you can take a fully written word or sentence, and condense it down into something shorter.
Simple abbreviations start with medical conditions and include:
- Diabetes = DM
- Hypertension = HTN
- Pressure ulcers = PU (or PI for pressure injuries)
Next, transitional statements. These look like:
- Because of = 2/2 (secondary to)
- After that = s/p (status post)
And finally, shorthand for common words such as:
- Discharged = D/C
- Doctor = MD
- Diagnosis = dx
And That’s It!
These 3 tips will help you with your nutrition assessment writing. You’ll be able to keep things short and to the point.
And when this happens, you have a fighting chance for the healthcare team to actually read your notes.
Need more than just an overview? Check out:
- Clinical Text Support for 1:1 conversations and answers to your specific questions
- Clinical Bootcamp for a deep dive in to medical nutrition therapy and the details of doing clinical nutrition in the real world
Want even more to help in clinical?
Check out The Nutrition Cheat Sheets Shop for all the nutrition education and clinical resources that will make your life easier.
