Record Keeping

Record keeping is an integral part of an effective dietetic practice. Clear, comprehensive and accurate documentation reflects a dietitian’s professional judgment, critical thinking and evidence-based dietetic practice. Essentially, it provides an account of the dietetic contribution to a client's health care.

Whether providing services to individuals, groups, populations, organizations, or the public at large, a  dietitian's documentation should always provide a clear picture of the needs or goals of the client, the dietitian’s  assessment of needs as well as the outcome and evaluation (as applicable) of those actions.

Good record keeping allows dietitians 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. 

Dietitians 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. Organized and systematic documentation will support streamlining records, maintaining confidentiality and prevent unauthorized disclosure.

Refer to our Record Keeping Professional Practice Resources for more information.