🗒️Clinical Documentation Review Criteria
This section outlines Berry Street’s quarterly clinical note review process to ensure clear, accurate, and compliant documentation.
Berry Street has instituted a clinical note review process to ensure provider documentation meets standard requirements for insurance billing and clinical care.
👉 This section covers:
Documentation Review Criteria
All providers will undergo a documentation review quarterly and notes are reviewed for the criteria below:
Clinical content: clinical documentation must be clear with succinct, relevant, and appropriate evidence-based nutrition practice recommendations and/or national guidelines/recommendations for standard of care based on client demographics and medical condition.
Cloned documentation: notes with information that has not been updated or revised from session to session.
Conflicting information: notes with inaccurate or conflicting information, this includes clinical and non-clinical information such as start/end/total appt times.
SMART goals: goals should be specific, measurable, achievable, relevant and time-defined.
Interventions: must contain one or more of the four domains within eNCPT.
Goal/Intervention updates: goals and interventions that do not change from one appointment to the next must be updated each appointment for progress and reinforcement.
MNT services are time-sensitive so accurate recording of appointment face-to-face start/end time and length is necessary and must be accurate.
Exact start time
Exact end time
Total appointment in minutes
Treatment Plan
The Provider must document and keep up to date treatment goals/plan that includes; appropriate history, examination, diagnosis, assessment, type of treatment/recommendations, date treatment protocol was initiated, regression or progress toward goals, and expected frequency and duration of treatments.
Berry Street clinical note templates are designed to be comprehensive and include all aspects of the treatment plan noted above:
Appropriate history, examination, diagnosis documentation should be documented in the initial assessment section “MEDICAL/HEALTH HISTORY”
Assessment and type of treatment/recommendations is included in the Initial assessment note section “GOALS & NEXT STEPS”
Date treatment protocol was initiated and regression and/or progress toward goals should be included in each Follow-Up note section “GOAL-SETTING”
Expected frequency and duration of treatments should be included in the “PROVIDER FOLLOW-UP/HOUSEKEEPING”
Supporting Documentation
Supporting documentation is any and all relevant clinical information and communications. This can include documents related to diagnosis, treatment, service, lab results, charting, billing records, collateral communications, invoices, documentation of shared education materials such as handouts, meal plans, and/or food journals.
Last updated