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From referral to signed note: where the hours actually go

A dietitian smiles as an older patient explains her history, with a printed referral letter on the desk between them

Ask a dietitian what takes the longest in a consultation and almost nobody says the assessment. They say the writing up afterwards.

This is a walk through one outpatient consultation, start to finish, with the parts separated into two piles: the work that requires a clinician, and the work that is transcription. It is worth doing that separation honestly, because the second pile is where software can help and the first pile is where it should not.

Before the appointment

The referral arrives as a scan. A fax that became a PDF, or a photo taken on a phone. Someone has to read it and re-key the relevant facts into the record: name, date of birth, referrer, diagnosis, medications, the reason for referral.

That is transcription. The clinical judgement is in deciding what matters, not in typing it twice. AI Dietitians reads the referral — photo or PDF — and populates the intake, creating the patient if they are new. You check it against the original, which is faster than typing it and also catches more, because you are reading rather than copying.

The history is unknown until they sit down. Most of the first appointment can go to establishing what a normal day of eating looks like, what else is going on medically, and what they actually want.

Some of that can happen before they arrive. A digital intake link sends the patient a form — health history, dietary snapshot, goals, funding — and the answers land in the record as a diff you review rather than as free text you re-enter. Ten minutes of the appointment becomes ten minutes of their evening.

During the appointment

This is the pile that does not move. Screening, measuring, interviewing, forming a clinical impression, negotiating a plan the person will actually follow: that is the job, and it needs the dietitian in the room.

What can sit alongside it is the reference material. Growth centiles, energy and protein requirements, fluid, micronutrients, refeeding risk, IDDSI levels, malnutrition screening — 25 calculators, in the same place as the patient record rather than across four browser tabs and a laminated card.

If you dictate, you can dictate. The transcription is structured into a clinical note rather than a wall of text.

After the appointment

This is where the evening goes.

The note. An ADIME note restates what you just did. The assessment data is already in the record, the diagnosis is the clinical judgement you already made, the intervention is the plan you already agreed. Writing it out is the third time that information has been handled.

AI Dietitians drafts the note from the work in the record, including the PES statement. You read it, correct what is wrong, and sign. The draft is not a clinical decision — it is the typing, done in advance, from your own inputs.

The letter to the GP. Same content, different audience and format. Drafted from the same source.

The handout. The patient needs something to take home that matches what you agreed, not a generic PDF about healthy eating. Handouts are generated from the plan and can be translated into ten languages, which matters more in Australian practice than any feature list suggests.

The meal plan. Built on the Australian Food Composition Database (AFCD), published by FSANZ — the current release, 1,588 foods — rather than an American database with the spelling changed.

What we are not claiming

We are not going to put a number on the hours saved. It depends entirely on how you currently work, what you dictate, what you template, and how much of your caseload is complex. Any single figure would be marketing rather than measurement.

What we will say precisely: every output is a draft, generated from information you entered, and nothing leaves the system until you sign it. The AI does not make the clinical decision, does not send anything on its own, and does not replace your documentation obligations. You remain the treating clinician and the author of the note.

That is not a disclaimer bolted on the end. It is the design: the drafting is automated because drafting is mechanical, and the judgement is not automated because judgement is not.

Try it on a real case

The honest way to evaluate this is not to click around an empty account. Take one referral you would normally work through by hand, run it through, and compare the draft against what you would have written yourself. If the output does not sound like you, that is the useful finding, and we would like to hear it.

You can also use the free tools with no account at all — Medicare items, NDIS line items, IDDSI and malnutrition screening are open to any Australian dietitian, whether or not you ever sign up.

References


AI Dietitians produces drafts to support clinical documentation. It does not provide diagnosis or treatment decisions, and the treating clinician remains responsible for all clinical content and for what is communicated to patients and other providers.

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