Clinical Notes
Structured SOAP and ADIME charting with templates, vitals, and file attachments.
MealCraft provides structured clinical charting using industry-standard SOAP and ADIME formats. Notes are linked to consultations, support vitals recording, and can be signed for permanent clinical records.
Note formats
MealCraft supports three clinical note formats:
| Format | Sections | Best for |
|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | Most nutrition consultations — the standard for clinical documentation |
| ADIME | Assessment, Diagnosis, Intervention, Monitoring, Evaluation | Advanced clinical workflows using the Nutrition Care Process |
| Custom | User-defined sections | Quick check-ins, phone calls, or specialized documentation |
SOAP is the default format and the most widely used in nutrition practice. ADIME follows the Academy of Nutrition and Dietetics' Nutrition Care Process framework — use it if your practice or institution requires NCP documentation.
Creating a clinical note
The fastest way to create a note is through the Start Visit flow from the Follow-ups tab. But you can also create standalone notes:
Open the Clinical Notes tab
Go to a client's profile and click the Clinical Notes tab.
Click "New Note"
Choose your format (SOAP, ADIME, or Custom), set the visit date, and optionally select a template.
Write your note
Each section has a colored badge and a text area. Fill in the relevant sections for this visit.
| SOAP Section | What to document |
|---|---|
| S Subjective | Client's self-reported symptoms, concerns, diet adherence, energy levels, sleep, cravings |
| O Objective | Measurable data — weight, measurements, BP, lab values, observed signs |
| A Assessment | Your clinical interpretation — diagnosis, progress evaluation, barriers identified |
| P Plan | Action items — diet changes, supplements, exercise, next follow-up timing |
Add vitals (optional)
Expand the Vitals section to record weight, blood pressure, pulse, temperature, SpO2, or blood sugar taken during the visit.
Save as draft or sign
- Save as Draft — you can edit later before finalizing
- Save & Sign — permanently locks the note (cannot be edited after signing)
Templates
Templates pre-fill section prompts so you don't start from a blank page. MealCraft includes system templates:
| Template | Format | Use case |
|---|---|---|
| Initial Nutrition Assessment | SOAP | First consultation — diet history, anthropometrics, diagnosis, care plan |
| Follow-up Review | SOAP | Progress check — adherence, weight change, plan adjustments |
| PCOS Management | SOAP | PCOS-specific — menstrual cycle, hormonal labs, anti-inflammatory diet |
| Diabetes Review | SOAP | Diabetes-specific — blood sugar logs, HbA1c, carb counting |
| Clinical Nutrition Assessment | ADIME | Full NCP assessment — PES diagnosis, intervention, monitoring plan |
| Quick Check-in | Custom | Brief phone/chat follow-up — progress, concerns, next steps |
You can create your own templates from any note. This is useful if you have a standard format for specific conditions like thyroid management or pregnancy nutrition.
Editing draft notes
Draft notes can be edited at any time before signing:
- Go to the Clinical Notes tab
- Find the draft note (marked with an amber "Draft" badge)
- Click to expand, then click Edit
- Make your changes and click Save Changes or Save & Sign
Once a note is signed, it is permanently locked and cannot be edited. This is by design — signed notes are legal clinical records. Review your notes carefully before signing.
Linking notes to consultations
Clinical notes can be linked to a specific consultation record. This connection is made automatically when you use the Start Visit flow, or manually when creating a standalone note.
The Consultations tab shows the link status for each session:
| Indicator | Meaning |
|---|---|
| 📋 SOAP note · Signed | A signed SOAP note is linked to this consultation |
| 📋 ADIME note · Draft | A draft ADIME note exists for this consultation |
| ⚠ No clinical note | This completed consultation has no documentation |
Click any consultation to expand it and see the full clinical note preview inline — no need to switch tabs.
Vitals recording
Each clinical note can include a vitals snapshot taken during the visit:
| Vital | Unit | Example |
|---|---|---|
| Weight | kg | 68.2 |
| BP Systolic | mmHg | 118 |
| BP Diastolic | mmHg | 76 |
| Pulse | bpm | 72 |
| Temperature | °C | 36.6 |
| SpO2 | % | 98 |
| Blood Sugar | mg/dL | 95 |
Vitals recorded in clinical notes are separate from the Assessments tab. Use Assessments for formal tracking over time (with trend charts). Use note vitals for quick in-session readings.
File attachments
Attach files from the client's Files tab to any clinical note — lab reports, prescriptions, progress photos, or any document relevant to the visit.
Note statuses
| Status | Badge color | Meaning |
|---|---|---|
| Draft | Amber | Editable — can be modified and signed later |
| Signed | Green | Permanently locked — legal clinical record |
Example: ADIME note for Rahul Verma (Diabetes)
| Section | Content |
|---|---|
| A Assessment | Male, 45 yrs, BMI 29.2. HbA1c 7.8% (↓ from 8.4%). Fasting glucose 128 mg/dL. Currently on Metformin 500mg BD. Diet recall shows high refined carb intake at dinner. |
| D Diagnosis | Excessive carbohydrate intake (NI-5.8.2) related to limited knowledge of carb counting as evidenced by HbA1c 7.8% and dinner recall showing 3 rotis + rice. |
| I Intervention | Carb counting education. Replace 1 roti with mixed vegetable salad at dinner. Add 15g protein (paneer/dal) to each meal. Reduce fruit juice, switch to whole fruits. |
| M Monitoring | Recheck HbA1c in 3 months. Weekly fasting glucose log via portal. Food diary review at next visit. |
| E Evaluation | HbA1c improved from 8.4% to 7.8% over 3 months. Client reports better energy. Continue current plan with dinner modification. |
The ADIME Diagnosis section uses PES (Problem, Etiology, Signs/Symptoms) format — the standard for nutrition diagnosis statements. The "Clinical Nutrition Assessment" template includes prompts for this format.