Clinical guide
Nutrition Documentation for Therapists
Write what the patient said, what you taught, and who you referred. Do not write a nutrition diagnosis you are not qualified to make.
A record that matches the visit
- Patient report: appetite, skipped meals, unplanned weight change, nausea, or a swallowing complaint, in the patient’s words.
- Observation: fatigue, a wound you are already treating, or an inability to complete the session.
- Education: the general points you actually gave, such as regular meals or a protein-containing food, and the handout if you used one.
- Referral: the profession you recommended and whether the patient agreed.
What to leave out
Do not chart “malnutrition” as your diagnosis because a screening score was high. Do not chart a calorie or protein prescription. Do not paste a supplement protocol from a course into the plan of care as an order. If a physician or dietitian has already set a diet, document that you reinforced it and that you did not change it.
Privacy and the team
Food insecurity, weight, and eating-disorder history are sensitive. Share them with the treating team for care, not in a hallway and not in marketing examples. Follow the same privacy rules you use for any other health information. A course certificate is not a release to discuss a patient publicly.
Related resources
Screening
The questions behind the note.
Scope
Why the note has to stay inside the license.
Profession paths
PT, PTA, OT, OTA, and athletic training are not the same scope.
Read the scope guide before you change your templates
Documentation follows the license. The scope page explains the boundary.