Record keeping is an integral part of effective dietetic practice. Clear, comprehensive and accurate documentation provides a record of a Registered Dietitian’s (RD’s) professional judgment and critical thinking applied to evidence-based dietetic practice. Essentially, it is an account of the RD's unique contribution not only to health care but also other dietetic services that RDs provide.
Whether providing services to individuals, groups, populations, organizations, or the public at large, an RD’s documentation should provide a clear picture of the needs or goals of the client/group, the RD’s actions based on the assessment of needs as well as the outcome and evaluation (as applicable) of those actions.
Good record keeping allows RDs to meet their professional, legal and ethical obligations. It provides a means for sharing information with other health care providers to avoid duplication and facilitate effective interprofessional collaboration. Records also enable clients to obtain copies of their care records, should such requests be made.
RDs can play an important role in ensuring that workplace systems, processes, policies and procedures facilitate the implementation of record and documentation guidelines. Workplace systems and processes for documentation and record keeping need not hinder the implementation of these guidelines and, in fact, can facilitate them. Approaching record keeping in an organized and systematic way will support streamlining records, maintaining confidentiality and prevent unauthorized disclosure.