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Hysio Dietetics
Discover the report structure based on the Dietetic Care Process (Diëtistisch ZorgProces): consultation, intake and evaluation, from dietary history and examination to diagnosis, treatment plan and follow-up.
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Three formats that match consecutive steps of the Dietetic Care Process.
For this profile, intake, consultation and evaluation are the three profession-specific documentation formats based on the Dietetic Care Process. The structure distinguishes history, examination, analysis, treatment, outcome and follow-up without adding any nutrition policy of its own.
For dietetics there are three formats: consultation, intake and evaluation. The choice matches the current step in the Dietetic Care Process. They are called Hysio Dietetic Consultation for a follow-up contact, Hysio Dietetic Intake for a first contact and Hysio Dietetic Evaluation for an interim or final assessment. This keeps dietary history, examination, dietetic diagnosis, intervention and goal attainment clearly separate from one another. You assess the measurements, the diagnosis, the treatment plan and the final choice for the record. Voice-driven reporting thus keeps each step of the Dietetic Care Process in its own documentation format. [2] [3] [4] [6] [7]
This format turns a follow-up contact into a clear dietetic journal entry along the Dietetic Care Process. It keeps the course of complaints according to the client, the dietitian's findings, assessment of the treatment outcome, interventions carried out, analysis during treatment and the adjusted dietary treatment plan clearly apart. Details of consultation with others and a closure or aftercare only appear when the contact actually contains them. Before transferring to the record, assess which information actually comes from that contact. [2] [7] [5]
The intake structure follows the Dietetic Care Process from registration and dietary history to examination, professional diagnosis, treatment plan and diet plan. Values keep their unit, method and time of measurement. The DTD outcome, information from the client, professional interpretation, goals, agreements and any supplementation remain separately recognisable. Only what was actually reported, measured or agreed is given a place in the report text. [3] [5] [6]
This format turns an interim or final evaluation into a report of treatment goals, the dietary treatment plan carried out, findings and measurement results, treatment outcome, the client's perspective, dietetic evaluation, follow-up or closure and aftercare. The evaluation framework comes first, so it is clear which goals you are assessing and against what. Then read the wording back against the original source and correct whatever the contact does not support. [4] [6] [7]
The consultation report is intended for a follow-up contact in which the course of complaints, current findings, treatment outcome, interventions carried out and new agreements are discussed. It does not replace a full intake or final evaluation. The structure keeps review and follow-up apart and only includes an adjusted dietary treatment plan when the dietitian has actually established that change and discussed it with the client. [2] [7] [5]
The intake organises the data from the first contact into fixed fields: referral route and reason for contact, request for help and expectations, medical health determinants, dietary history, relevant measurements, dietetic examination, goals and agreements. Statements by the client stay recognisable as a client source; a laboratory result and a referral diagnosis remain external sources. Hysio does not calculate any missing value and does not derive a diagnosis from isolated data. The dietitian then assesses whether each component belongs to this first contact. [3] [5] [6]
The evaluation report is intended for the moment when treatment goals, interventions carried out, measurement results, the client's perspective and goal attainment are assessed together. A regular contact with only progress and a minor adjustment fits the consultation better; a first contact with screening and planning belongs to the intake. The dietitian determines whether an evaluation moment was actually agreed and whether the outcome can already be assessed. [4] [6] [7]
The consultation report contains the course since the previous contact, current findings, guidance provided, the dietitian's analysis and concrete next steps. An intervention already carried out is not listed among the future agreements. Only explicitly continued or adjusted goals go into the plan, and consultation with others or aftercare only when the contact supports it. This way you review the text in a targeted way before components go into your own record. [2] [7] [5]
The overview for dietetics contains three documentation formats that each cover a different moment in the Dietetic Care Process. The intake belongs to registration, screening, examination and planning. The consultation belongs to treatment and its progress. The evaluation belongs to the assessment of outcome, goal attainment and closure. This keeps history, analysis, intervention, goal attainment and closure clearly distinguished instead of in one continuous narrative. [2] [3] [4] [7] [5]
The intake organises registration and screening, history, dietary history, dietetic examination, dietetic diagnosis, treatment plan and diet plan. It thereby covers the first four steps of the Dietetic Care Process; evaluation and closure belong to the other two formats. The order of the headings follows the order of the care process, so that examination and diagnosis do not get mixed up. Hysio does not choose a diagnosis or dietary goal independently and does not add any nutritional data that you have not recorded. [3] [5] [6]
The NVD guideline on record keeping connects to the Richtlijn Informatie-uitwisseling tussen arts en paramedicus (guideline on information exchange between doctor and allied health professional), also known as HASP-paramedicus, from NHG and LHV dated December 2020. When consulting a doctor, use a fixed, traceable structure for the reason, relevant nutritional information, professional assessment and request or agreement. Record what was actually exchanged and which follow-up action lies with which healthcare professional. [1] [5] [6]
A first conversation starts with the request for help and what the client says about eating and drinking patterns, complaints, possibilities and expectations. Then relevant measurement data, the DTD outcome, examination and professional interpretation each get their own place. Goals and a diet plan only appear once they have been discussed. The intake structure thus preserves the order from source information to analysis, without independently filling in missing connections. [3] [6] [7]
In an evaluation, four parts stay separate: the treatment goals assessed, the dietary treatment plan carried out with the related findings and measurement results, the outcome as the client experiences it, and your own dietetic conclusion. Follow-up, aftercare and goal adjustment come after that, only when they have been discussed, and stay separate from interventions that have already been carried out. [4] [7] [5]
Within the Dietetic Care Process, the follow-up consultation belongs to treatment and progress monitoring. The structure brings together the policy carried out, the client's response, current measurements, goal attainment and any adjustment within step four. The final evaluation and closure, steps five and six, belong in the evaluation format. The report makes visible what is review and what counts as the next step; the assessment stays with the dietitian. [2] [5] [6]
The intake report must provide a traceable basis for examination, professional diagnosis and planning. That is why registration, dietary history, measurement data, the client's expectations, the DTD outcome and consent stay clearly separate. The structure helps keep missing information visible and prevents a statement by the client from being presented as a measured fact. The dietitian ultimately decides which rationale and goals belong in the record. [3] [6] [7]
The evaluation links each discussed treatment goal to relevant findings, measurements and the client's perspective. This is followed by the dietitian's assessment: achieved, partly achieved, not achieved or not yet determinable, only when that outcome has been stated. Continuing, adjusting, closing and aftercare remain separate follow-up decisions. Hysio does not derive goal attainment from a single isolated value and does not fill in a missing time of measurement. [4] [7] [5]
The report text after a follow-up consultation only contains information from that contact: changes since the previous appointment, relevant findings, interventions carried out, the dietitian's current assessment and the agreed follow-up. A product, supplement or new nutritional goal is not added because it seems likely. Missing information stays visibly missing. Compare the text with the source and decide which components are complete and accurate enough to save. [2] [5] [6]
In an intake, Hysio only includes the referral route and a DTD outcome when the dietitian has explicitly assessed them. DTD stands for directe toegankelijkheid diëtetiek (direct access to dietetics); the screening conclusion is then, exactly as in the source, pluis or niet-pluis (no concern or concern), with no intermediate form. Hysio does not derive urgency or a referral from complaints. A decision to request information, share it with the GP or refer is only recorded as an agreement when it has been stated. [3] [6] [7]
A follow-up consultation can contain the course of complaints, findings, treatment outcome, interventions carried out, analysis, consultation with others and an adjusted dietary treatment plan, plus a closure or aftercare when relevant. The text stays linked to what was discussed during the contact. Hysio does not turn a passing remark into new nutritional advice and does not present a change that was not stated as a decision. Hysio Dietetic Consultation is the format that belongs to this moment of contact. [2] [6] [7]
The evaluation is intended for the moment when you want to bring together the evaluation framework, the treatment goals, the interventions carried out, measurement results, goal attainment, the client's perspective, your dietetic evaluation and the follow-up or closure in one report. Hysio organises those components when they have been discussed and does not itself declare a goal achieved, nor a course of treatment closed. For an ordinary progress contact, the consultation is the appropriate format. [4] [7] [5]
Article 454 of the WGBO requires the dietitian to set up a record of the treatment. It contains necessary data on the client's health, interventions carried out and other information that good care requires. Record only relevant data, keep the source recognisable and prevent an assumption from being saved as a measured or professionally established fact. [1] [7] [5]
Within the WGBO, the duty to inform, consent, the duty to keep records, the retention duty, destruction, access and confidentiality are all connected. Inform the client about intended examination, treatment and relevant developments. Share data only on a valid legal basis and record consent or an applicable exception in a traceable way. For periods and exceptions, always use the current legal text and legal practice information. [1] [5] [6]
Dietitian is a protected professional title under Article 34 of the Wet BIG. The healthcare professional works within the legally defined area of expertise and remains personally responsible for professional practice. No mandatory BIG registration is attached to this title, as there is for Article 3 professions; quality registration runs through the Kwaliteitsregister Paramedici (quality register for allied health professionals) and is a separate route. Describe the professional status precisely and do not suggest that every dietitian has a BIG number. [1] [6] [7]
The Wkkgz sets requirements for good care, complaint handling and learning from incidents. The NVD guideline names this law as a relevant framework for dietetic record keeping. Record client-related care information in the record, but for complaints, incidents and quality reports follow the organisational procedure designated for them. Do not automatically mix these routes with the ordinary treatment report. [1] [7] [5]
The central source in this dossier is the NVD-richtlijn Diëtistische dossiervoering 2023 (NVD guideline on dietetic record keeping), issued by the Nederlandse Vereniging van Diëtisten and published in September 2023. The publication names Yvonne Heerkens, Sytske Runia, Willy Visser, Louise Witteman and José Tiebie as editors. When applying it, always check the current version and scope on the primary NVD page, because a later revision may replace this source. [1] [5] [6]
The NVD guideline does not stand on its own. For information exchange it refers, among others, to HASP-paramedicus and the Informatiestandaard Paramedische Zorg (information standard for allied health care) from Nictiz, which is still under development. Within medical specialist care, the Basisgegevensset Zorg (basic care dataset) and the zorginformatiebouwsteen Voedingsadvies (care information building block for nutritional advice) connect to it. Choose only the data needed for the specific handover, keep source, date and professional interpretation recognisable, and check the current version of a standard before you build on it. [1] [6] [7]
The label (WGBO) marks an item that is mandatory under the WGBO itself; the other items that are mandatory by definition are mandatory because the NVD considers them essential for dietetic critical reasoning, not because of a direct statutory provision. When reviewing, distinguish between the client's report, observation and professional interpretation, while a missing measurement or agreement also stays visibly missing within dietetics. [1] [7] [5]
The dietetic diagnosis forms the link between examination and treatment plan. It is the only step of the Dietetic Care Process with exactly one item that is mandatory by definition: the diagnosis itself, including the nutritional problems in relation to cause and effect. Record that connection only when the collected data and your reasoning support it. An isolated measurement or statement by the client is not yet a diagnosis in itself. [1] [5] [6]
The NVD guideline describes registration, examination, diagnosis, treatment plan and treatment, evaluation and closure as consecutive steps. Hysio does not translate that professional structure into nutrition policy of its own, but organises the components that you record during an intake, consultation or evaluation. The chosen documentation format determines which step is in the foreground. That way, voice-driven reporting follows the steps you already know. [3] [4] [5] [6]
The dietary history describes what the client says about eating and drinking patterns, context and experience. The dietetic examination describes the additional data and measurement or observation findings that you collect. Hysio does not convert a statement into an objective measured value and does not mix your analysis with the client's source. [3] [6] [7]
Critical reasoning means that you interpret, analyse, explain and evaluate collected data to arrive at a well-founded diagnosis and treatment choice. Make visible in the record which information comes from the client, a measurement or an external source, and where your professional interpretation begins. A missing connection is not constructed from isolated data. [1] [6] [7]
A dietetic diagnosis describes the core problems in functioning and links nutritional problems to relevant medical, external and personal factors. It is a functional diagnosis and explicitly not a medical diagnosis, nor a list of complaints or measured values. It contains a clear conclusion with as much measurable support as possible. Record the source information and your reasoning in a traceable way and make uncertainty visible when cause or effect is not yet sufficiently supported. [1] [7] [5]
Record expectations in the client's own words and keep them separate from professional goals or treatment advice. Note what someone expects from the guidance, outcome or collaboration, and discuss any differences with what is considered achievable or appropriate. An expectation is not an agreement until explicit agreement has been reached on it and the follow-up has been recorded. [1] [5] [6]
A dietetic intervention covers the actions carried out within the Dietetic Care Process. These can be diagnostic activities, such as examination, or preventive and therapeutic parts of treatment. Describe what was actually done, with what aim, and which outcome or follow-up was discussed. Keep an intended intervention separate from an action already carried out. [1] [6] [7]
Consistent terminology makes data comparable and reduces differences in interpretation. So use agreed values in fixed fields: pluis or niet-pluis (no concern or concern) for the screening conclusion, a Bristol Stool Chart type for stool consistency and an IDDSI level for food consistency. Record such a scale value exactly as you say it, without translation. Also note the source, measurement method and context when needed. In AI reporting, it helps to use those fixed terms out loud. [1] [7] [5]
The Classificatie Diëtistische Interventies (classification of dietetic interventions) from 2023 organises diagnostic, preventive and therapeutic actions within the Dietetic Care Process. The guideline recommends the codes but does not make them mandatory. Use a code only when it matches the intervention actually carried out, and keep enough plain language in the record to understand the aim, content and follow-up. [1] [5] [6]
A message to a GP or medical specialist should be brief, collegial and relevant to continuity of care. Follow the structure of HASP-paramedicus and state the reason, key findings, professional conclusion, current treatment and the concrete question or agreement. Share only necessary information, make clear who the source is and assess the consent or other legal basis for the exchange. The dietetic formats do not write a letter themselves and do not send anything; correspondence is a separate step. [1] [6] [7]
The choice described belongs to the evaluation format within dietetics. The evaluation is intended for the moment when you assess goal attainment, treatment outcome, the client's experiences and the continuation of the dietary treatment plan. An interim version supports adjustment; a final version also describes the reason for completion and aftercare. Link measurement results to method and time of measurement, and leave any conclusion or follow-up appointment that was not discussed out of the report. [4] [7] [5]
Hysio does not independently propose a diet, supplement or medication. The platform organises a diet plan, intervention or discussion of supplementation only when you record it as source information. It does not devise a dosage or product choice and does not assess suitability outside the conversation. You remain responsible for the professional content, the rationale and the agreements you save in the record. [2] [3] [4] [7] [5]
A PES statement, meaning problem, aetiology and symptoms, is a lens for organising within the dietetic diagnosis and not a stand-alone report structure. Record the relationship between problem, cause and effect only when you have formulated and stated it. Hysio puts the statement in the right place in the intake report, but does not create its own PES sentence from isolated nutritional data and does not fill in a missing cause. [3] [5] [6]
The general Starter rate for one person starts at €20 per month excluding VAT, good for around 50 sessions. Pro costs €40 per month for around 100 sessions and Unlimited €80 with a fair-use limit. With yearly billing, you get two months free. For a dietetics practice, contact volume matters most: count your intakes, follow-up consultations and evaluations per month and compare that with the current pricing page. [2] [8]
Use only information that is needed for the care purpose, especially with health data, laboratory results and personal eating context. Record who starts a recording, who has access, who reviews the report text and how the text goes into the record. Within this processing, Hysio acts as processor and the practice remains the controller. Consult the current privacy and legal information for details. [3] [10]
Automatic saving in your record system does not take place. There is no direct integration, so you review the text and transfer suitable components yourself according to your practice's way of working. For an intake these can be dietary history, dietetic examination, dietetic diagnosis, treatment plan and diet plan; for an evaluation, goal attainment, conclusion and follow-up. Ask your own supplier which transfer is possible; this page does not promise any specific integration. [4] [12] [11]
In the consultation, Hysio separates what has already been carried out from what has been agreed for later. A discussed behavioural intervention, the current assessment of goal attainment and the source-based analysis each get their own place. Only explicitly continued or adjusted goals, self-monitoring, practical agreements and the next contact go into the follow-up plan. A change that you have not stated will not appear in it. [2] [5] [6]
The dietary history contains what the client reports about intake, eating moments and context. Measurements get their value, unit, method, time of measurement and source role. A dietetic diagnosis only appears in the report as a stated professional judgement. Hysio does not calculate a BMI or score and does not turn a laboratory result into a measurement of the dietitian's own. [3] [6] [7]
Compare the report text with the original source and separate the client's report, measurement, dietetic diagnosis, intervention and agreement. Pay attention to value, unit, time of measurement, negations and the relationship between problem, cause and effect. A text from Hysio remains working material and may contain errors; the platform does not calculate any missing score and does not devise any dietary policy. The dietitian corrects and approves the final content. [4] [11]
Alternatives are writing by hand, a fixed template of your own, general dictation support or a platform focused on the profession. A short follow-up contact is sometimes quicker to process by hand; an extensive intake with dietary history and examination usually takes the most time manually. Compare the options on professional language, source roles, measurement data, correction time, privacy and the step into your own record, and assess whether the structure of the Dietetic Care Process stays recognisable. [2] [11]
The Hysio trial period lasts 14 days, with no credit card and cancellable monthly. Use those two weeks in a focused way in your own practice. Compare a follow-up consultation and evaluation on history, measurements, goals, source roles, corrections and transfer time. Hysio organises the information you dictate; you check the professional content and decide which components go into your record. Note missing units and discuss deviations within your own care process. [3] [9] [8]
Measure per documentation format and not in general. Intake, follow-up consultation and evaluation require different amounts of correction, so measure them separately and not as one average. First time your current way of recording, then the route of dictating, reviewing, correcting measurement data and transferring to the record. Also note source errors and missing units. That way you see what admin with AI brings you, without adopting a general savings claim. [3] [4] [11]
At every step, start with a careful review of dietary history, measurements, dietetic diagnosis, goals and agreements. Begin with one type of contact, for example the follow-up consultation, and agree who checks the text and how it ends up in the record. Arrange privacy and transfer to the record before you scale up. Then expand to intake and evaluation, as long as the steps of the Dietetic Care Process stay recognisable. You keep the professional decision and the final saving in your own hands. [2] [3] [4] [10] [11]
Hysio creates the report. You remain responsible for what you save in the record.