Dietitian Template

Seven Step Session: Every Client Every Session

A professional Dietitian template for healthcare professionals.

About this template

Need a structured way to document your sessions? This 'Seven Step Session' template is perfect for dietitians and other health professionals. It guides you through each session, covering client comfort, demographics, assessment, plan initiation, education, creating space for questions, and retention strategies. This template ensures a comprehensive record of each client interaction, helping you track progress and tailor your approach. With Heidi, this template can be quickly populated from your session transcript, saving you time and improving the quality of your notes. Streamline your practice and enhance client care with this efficient documentation tool.

Preview template

Step 1: Client Comfort Today's session began with a warm welcome and a brief recap of the previous week's progress. We discussed the client's goals for the session, which included reviewing their food journal and discussing strategies for managing cravings. The client appeared relaxed and engaged throughout the initial rapport-building phase. Step 2: Demographics * Patient Name: Jane Doe * Contact Information: 07700 900000, jane.doe@email.com * Referral Source: Dr. Smith * Insurance Information: NHS Step 3: Client Assessment Medical History: The client reported no new medical issues since the last session. She continues to manage her type 2 diabetes with medication and diet. She reports no allergies. Lifestyle History: Jane reports eating a balanced diet, with a focus on whole foods. She exercises three times a week for 30 minutes each time. She sleeps approximately 7-8 hours per night and reports feeling well-rested. She reports moderate stress levels related to work. She has a strong support network of friends and family. SSOS Assessment: * Successes: Adhering to her meal plan, regular exercise, and consistent blood sugar monitoring. * Struggles: Managing cravings for sugary snacks, especially in the evenings. * Opportunities: Exploring new healthy recipes and incorporating stress-reducing activities. * Strategies: Developing a plan to manage cravings, including identifying trigger foods and implementing distraction techniques. Step 4: Plan Initiation or Adjustment Sustainable Success Strategies: * Plan meals in advance. * Keep healthy snacks readily available. * Drink plenty of water throughout the day. SMART Goals: * Goal 1: Reduce sugar intake by 25% within the next two weeks. * Goal 2: Exercise for 30 minutes, four times per week. * Goal 3: Track food intake daily using Nutritionix. Step 5: Client Education Education was provided on the importance of portion control, reading food labels, and identifying hidden sugars in processed foods. The client was encouraged to focus on whole, unprocessed foods and to limit sugary drinks. We discussed strategies for managing cravings, such as drinking water, going for a walk, or calling a friend. The client was also educated on the importance of regular exercise for blood sugar control and overall health. Platforms: * Nutritionix (food journal) Step 6: Creating Space The client was given time to review the information and ask questions. She expressed understanding of the strategies and goals and felt confident in her ability to implement them. She stated she felt she had everything she needed for the session. Step 7: Retention Follow-up Appointment: 8 November 2024 at 10:00 AM. Health Coach Tasks: Review food journal entries and provide feedback on meal planning.

Step 1: Client Comfort [Document introduction and outline of expectations for session, including any rapport-building discussion or orientation to the process.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.) Step 2: Demographics [Document patient name, contact information, referral source, and insurance information confirmed or updated during the session.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as list.) Step 3: Client Assessment [Document relevant medical history obtained during session.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.) [Document relevant lifestyle history including dietary habits, exercise patterns, sleep, stress, and social factors.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.) [Document SSOS (Successes, Struggles, Opportunities, Strategies) assessment findings, including recommended strategies identified.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in bullet points.) Step 4: Plan Initiation or Adjustment [List Sustainable Success Strategies developed during session.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in bullet points.) [List 1–3 SMART goals established with client.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in bullet points.) Step 5: Client Education [Document education provided on Sustainable Success Strategies, motivation, barriers, and expected compliance.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.) [Document introduction of platforms such as Nutritionix (food journal), MealGarden (meal planning), Renpho Scale, glucose monitor, or blood pressure cuff for remote monitoring, if discussed.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as list.) Step 6: Creating Space [Document pause given to client to review education and ask questions.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.) [Document client feedback on whether they have what they need for today and if they feel confident about their Sustainable Success Strategies and SMART goals.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.) Step 7: Retention [Document follow-up appointment date and time set with client.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Document BodySite program scheduling for ongoing engagement.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Document health coach tasks assigned (food journal review, meal planning assistance, remote patient monitoring review) as appropriate.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output; just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all relevant information from the transcript.)

Browse more templates

Use this template