ADIME and SOAP notes drafted inside a HIPAA tool
Charting is what keeps dietitians at their desks after the last client leaves. AI scribes built into HIPAA-compliant platforms like Healthie, Practice Better, and Twofold draft ADIME or SOAP notes from the visit, and practitioners report cutting documentation time by 50-75% and reclaiming 15-20 minutes per session. The catch is that this only works inside a tool with a signed Business Associate Agreement — never a consumer chatbot.
You are a clinical documentation assistant running inside my HIPAA-compliant practice platform. Turn my rough session notes into a structured {{note_format}} note for a {{setting}} visit. Session notes (entered only within this secure, BAA-covered tool): {{session_notes}} Rules: - Use only what I recorded. Do not invent measurements, intake amounts, lab values, or diagnoses. If a field has no data, write [MISSING — clinician to complete]. - Write a clear PES statement (problem, etiology, signs/symptoms) drawn strictly from my notes, and flag it [CONFIRM PES] so I verify it. - Keep assessment and plan factual and concise; do not add clinical recommendations I did not state. - Mark anything you inferred rather than something I explicitly recorded. Return the note in standard {{note_format}} sections, ready for me to edit and sign.
Fill in your details and the prompt updates live — then copy.
ADIME note Assessment: Client reports improved appetite and ~80% adherence to protein goal; weight down 1.2 kg since last visit. Breakfast frequently skipped. Labs this visit: [MISSING — clinician to complete]. Diagnosis (PES): Suboptimal protein intake related to skipped morning meal as evidenced by self-reported 80% goal adherence and omitted breakfast. [CONFIRM PES] Intervention: Discussed portable breakfast options to close the morning gap. Monitoring/Evaluation: Recheck weight and protein adherence next visit.
The full workflow
- Use only an AI scribe covered by a signed BAA with your EHR — confirm the BAA extends to the AI feature, not just the base subscription
- Let the tool draft the note from the session, then read every line for accuracy
- Confirm the PES statement and complete each [MISSING] field with real recorded data
- Edit into your own clinical voice and sign; the note is your responsibility, not the model's
Watch out for
Privacy: this belongs only in a HIPAA-compliant, BAA-covered platform. Never paste a client's session details, name, or labs into consumer ChatGPT, Gemini, or Copilot — those are not covered and treat your inputs as training data.
Verify the note: AI scribes hallucinate values and misattribute statements. Check the PES statement and every number before signing — you are attesting to it.
Nutrition-specific templates often need manual cleanup after import; don't assume a generic medical scribe formats ADIME correctly.
Where this comes from
Every use case on this site is grounded in real reports from working nutritionists — not invented by us.