How to Document Private Practice Sessions Without Wasting Hours
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[00:00:00] Welcome to today's podcast episode. I'm Libby Rothschild, founder of Dietitian Boss, where I help you grow your business. In today's episode, we're talking about an important topic. That's how to write session notes and do so faster in private practice. So many of you ask about AI tools, meaning tools that can help you get your work done faster.
your concern might be, how is this compliant? Where do I get started? What tool to use? So I'm gonna break these questions down for you in today's episode. If documentation feels draining, and if it feels like your energy's been eaten up even in your evenings because you're taking so long with session notes, you're not alone.
This is a really common concern for Dietitians and other practitioners as well, such as therapists and doctors. So in today's episode, I'm gonna show you how to cut your charting time in half using what's called smart workflows, meaning simple processes. And free tools that use AI to [00:01:00] speed up the process, and you're not gonna lose control or quality, or clinical integrity in the process.
In today's episode, we'll also talk about how to stay transparent with clients, because when you're using ai, you wanna be clear that you're using AI and you still wanna build trust through smart and standardized documentation systems. So first I wanna talk about a repeatable framework.
When you create repeatable frameworks, you are going to cause less energy from yourself, and you're also creating standardized processes. So it's a really solid way to create business structure. So one of our Dietitians who specializes in PCOS, she did used to write every single note from scratch, right?
But writing notes from scratch can take a long time, and she'd spend 30 minutes. second guessing herself using the SOAP format, and she felt overwhelmed with this. Not sure if her note was structured appropriately. And so here at Dietitian Boss, we gave her streamlined note structure with simple prompts.
If you [00:02:00] use the SOAP format s what the client said, that's a quote or a summary. O observations, lab, weight, mood and behavior. A would be alignment. how it ties to client goals and P would be plan. Next step, referral and education. So once our client had the structure and she added AI support, she did cut her note time to under 10 minutes per session.
And you can do that too, whether you're already writing consistent notes or you want to, alright, the second step here would be to use smart tools like Heidi. You might have heard of that. That's a free software tool that you can sign up for or practice better now. Practice better.
Is they have an integrated ai, I don't know what it's called, but they use AI with practice better as an add-on. And once you add it onto your, EMR, meaning your software and it's simple and easy to integrate it, then you, when you are with clients, the session is recorded and it writes the note for you.
So let's talk about how this tech works now. That's only if you're using the practice better. [00:03:00] Platform. I'm not familiar with every single EHR and how they integrate ai. I know Simple Practice does not yet integrate AI for note taking, and I know Practice Better does. So again, this is gonna depend on your EHR.
That doesn't mean that other EHRs are bad if they don't integrate AI the way that Practice Better has. But it is a really cool feature in practice. Better If you wanna use practice better, we have a referral code in our show notes [email protected].
Heidi, it's free. So no matter what platform you're using to document your notes, you can go ahead and use Heidi. It's an assistant built for healthcare practitioners and Dietitians can use it. All right? You just, what you're gonna do is you're gonna start Heidi, and it takes a recorded session and it doesn't record a transcript.
It just listens, and then it writes a note for you, and you can choose if you want to use the soap or aine format, you can toggle between the two. And what cool part is, even after it, listens to and writes the note for you, you can change the style. So if you wrote it in soap and you're like, you know what?
I [00:04:00] wanna see what AON looks like, you can absolutely switch that, if you do use practice better. Their builtin AI tools offer note suggestions and smart autofill features, and it's right inside your client chart. It's super easy. That's what I love about Practice Better, is that their integrated AI tool doesn't require an external browser to be open.
So with Heidi. You have to open your EHR and Heidi alongside like together, because it's not integrated and so it's an extra step. Not impossible, but it's just one extra thing you have to do in session. You also have to press record externally and press stop after the session for Heidi. Where with practice better, you don't.
When you start the session, the integrated AI starts and when you stop it, it ends. One of our clients was able to use both like me, and he used Heidi to draft it and then practice better to clean it up. if you're already using an EMR that does not include an integrated ai, then use Heidi.
If you're already using Practice better, absolutely use their integrated AI feature. It's amazing. I've used it and it's really fantastic. [00:05:00] The next step would be to practice on mock clients first if you're feeling uncomfortable. Go ahead and give it a try so that you can feel more comfortable when you're in session.
One of our clients wasn't sure how to phrase her goals or even how to prioritize in the notes itself. So she started using our case study simulations, which we've made available inside of our library, a Dietitian boss to practice documentation, and that's a low stakes environment, right before even applying it live.
So now she can spot alignment faster and write notes more confidently because she's mastered. These case study simulations that we provide you with, we actually have 33 different simulations. There are 11 different specialties with three levels each for clinical and for sales. So these are really great opportunities for you to see how are you charting, can you practice?
What can you do to tighten up your workflow, right? And you can make some tweaks and you can test AI without testing on an actual patient, right? You're testing on a simulation [00:06:00] that we've presented you with. Inside of our library, you're gonna find documentation and practice via mock client scenarios.
You're gonna find sample, soap and sample aime notes and editable templates that you can pair, and you also will get a form pack. And what that shows you is how to set up the intake form for your initial sessions, how to frame out, your policies and procedures, and, some food logs, questions that you might have about release and, medical release.
And also testimonial and feedback. So there's a lot of great forms that I've designed for you that are used in private practice that you can have access to once you join the library. Of course you can modify them on your own, but you can at least see an example. Now these work for insurance or cash, so you can modify how you run your business based on these templates.
Alright? So you're not hiding it inside of our client form bundle that I just mentioned inside the library. I actually show you how to frame this language so that clients know how their data's being processed, especially when AI's involved.
[00:07:00] And that's not only gonna protect your practice, but it builds trust and it helps you stay compliant across cash pay and insurance clients. So what this means is we include a customizable AI disclosure section and editable intake consent and documentation forms and hipaa safe structure and optional language for EMR uploads.
Alright, so if you wanna try, Heidi, our practice betters AI. But you're not sure how to structure your notes or talk to clients about it, definitely check out the library because we walk you through how to do this and you can plug and play to make sure you're being clear and standardized. Because remember, once you have a system going for your notes with your clients, you're gonna feel more confident and charting is gonna take less time, and you're also gonna be more consistent across the board between clients, which is really important.
You don't have to choose between quality and speed inside of the library. You'll get. templates, case study simulations for practice, and a complete client facing forms in a bundle including AI disclosure language. [00:08:00] Alright, you can [email protected]. Go over to the library page.
Alright. It's right in the home page and you can click the button and join today We look forward to seeing you inside the library.
