AI scribe and clinic software for dietitians

The dietetic note, assessment to plan

Most dietitians structure the assessment around anthropometry, biochemistry, clinical findings, dietary intake and environmental and social factors, then a nutrition diagnosis, goals and an intervention plan. wai reads the same captured note in SOAP, problem-oriented or narrative view, and the clinic's own assessment template and phrase library are shared across every dietitian.

Screening sets the action. NICE recommends screening all outpatients for malnutrition at their first clinic appointment, assessing BMI, percentage unintentional weight loss and the time over which intake has been reduced, and names the Malnutrition Universal Screening Tool, MUST, as one way to do it.¹ It defines malnutrition as a BMI under 18.5, unintentional weight loss of more than 10% within 3 to 6 months, or a BMI under 20 with more than 5% unintentional loss in that time.¹ wai suggests the screening score from the figures said in the room, for the dietitian to apply.

Weight management uses different thresholds for different patients. NICE's 2025 obesity guideline says people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean background have cardiometabolic risk at a lower BMI, and classes overweight in those groups from 23 and obesity from 27.5.² The template records the patient's background and waist-to-height ratio beside the BMI, so the classification in the draft is the right one.

Eating disorders set a boundary. NICE says not to use single measures such as BMI or duration of illness to decide whether to offer treatment, to refer immediately to a community, age-appropriate eating disorder service when an eating disorder is suspected after an initial assessment, and to offer dietary counselling in anorexia nervosa only as part of a multidisciplinary approach.³ wai runs a safety-netting check on every draft, and drafts the referral from the consultation for the dietitian to sign the same day.

Codes come from the note. wai suggests ICD-10 and SNOMED CT codes, each beside the line of the consultation it rests on, for the dietitian to confirm. In the WHO ICD-10 used in the UK, typical ones are E66.9 for obesity, unspecified, E44.0 for moderate protein-energy malnutrition, K90.0 for coeliac disease, R63.4 for abnormal weight loss and Z71.3 for dietary counselling and surveillance. US ICD-10-CM uses the same codes with slightly different titles, such as E44.0 for moderate protein-calorie malnutrition. Procedure and billing codes stay with the clinic's biller.

Letters to the GP, the referrer and the patient

The GP letter carries requests. After an assessment, the GP or referring consultant needs the screening score, the nutrition diagnosis, the plan and anything the dietitian is asking for, such as repeat bloods or a prescription for oral nutritional supplements, written as an explicit request. wai drafts that letter from the consultation, and referral letters to a gastroenterologist, endocrinologist or eating disorder service carry the question for the specialist, as the referral letter describes.

The patient letter is the plan. The Academy of Medical Royal Colleges recommends writing most outpatient letters directly to the patient with a copy to the GP, and says writing to patients should be the default for an AI scribe.⁷ For a dietitian, that letter restates the goals in the patient's own words, the meal plan, the practical swaps agreed and the date of the next review. A medication change letter covers changes to insulin timing or supplements when the prescriber has agreed them.

Diet histories in the patient's own language

A diet history is only as good as the words for the food. wai works in 60 languages, among them English, Arabic, Spanish, French, Portuguese, Italian, Russian, Polish, Turkish, Urdu and Mandarin. English can be mixed in one consultation with Spanish, French, Portuguese, Russian, Italian, Dutch, German, Hindi or Japanese, and the other languages are captured in that language, so a patient can describe a day's meals in the words they cook with.

This matters most where NICE says risk starts at a lower BMI. Patients of South Asian, Chinese and Middle Eastern background are named in the obesity guideline, and Urdu, Mandarin and Arabic are among wai's languages.² The signed note is written in English, and the patient's plan can be translated into their language beside it, with emergency numbers kept exactly as written. The multilingual scribe page shows how.

Clinic software for dietetics clinics, from programme to review

Dietetic care is a series of reviews. Patients request appointments through booking links that read each dietitian's calendar, in person or by video, and the scribe joins Google Meet, Zoom and Microsoft Teams calls. Reminders go out before each review, cancellations are offered to the waitlist, and wai's proactive care sends a recall when a review or a repeat blood test is due, each message approved by a person.

Weight management programmes run as memberships through the clinic's own Stripe account, with deposits, payment links and insurer invoices for single appointments. In the UK, blood tests go out and results come back through TDL, and each result reaches the patient with the dietitian's comment and a plain explanation of each marker.

Calls, email, web forms and WhatsApp land in one thread per patient, so a question about a recipe and a question about a symptom sit in the same place, and every drafted reply is approved before it is sent. Before each review the dietitian sees a sourced brief with the weight trend, recent results and the goals from last time, each traced to its source. The clinic management software page shows the full front desk.

One first consultation, start to finish

Take a 52-year-old shop owner referred by his GP after a blood test showed raised HbA1c in the prediabetes range. He speaks Urdu, and the consultation is captured in Urdu. He weighs 81 kg at 1.70 m, a BMI of 28.0, and his waist is 101 cm. He eats late after closing the shop, has two cups of sweet tea a day, cooks with ghee and walks very little.

The dietitian takes a diet history through a typical working day and a weekend day. They agree three goals in his words, eat the main meal before 8pm, switch to one sweetened tea a day, and walk to the shop three days a week, with smaller portions of rice and chapati at the evening meal and a review in six weeks.

The draft note set out the anthropometry, the HbA1c, the diet history by meal, the goals and the plan. It had classed the BMI as overweight, and the dietitian corrected it to obesity under the NICE threshold for people of South Asian background.² wai suggested E66.9 for obesity and Z71.3 for dietary counselling, and the dietitian confirmed both and signed.

What went out was a letter to the patient, with an Urdu translation of the goals and the meal plan beside the English, and a copy to the GP with the assessment, the plan and a request to repeat the HbA1c before the review. The front desk sent a booking link for the six-week review and set a recall for the repeat blood test.

The evidence behind wai's method

The note is one part of the day the evidence measures. In a randomised trial of 238 outpatient physicians across 14 specialties at UCLA Health, the ambient scribe with a significant effect cut the time spent writing each note by about 41 seconds, against 18 seconds in usual care.⁵ At The Permanente Medical Group, 3,442 physicians used an ambient scribe across 303,266 encounters in its first ten weeks.⁶ Dietitians were not studied, and a dietetic consultation is longer and more conversational than most, so wai also drafts the letters and the plan and runs the reviews.

The regulator asks for complete, prompt records. The HCPC standards, in effect since 1 September 2024, require full, clear and accurate records completed promptly and as soon as possible after care.⁴ wai holds every draft until the dietitian signs it.

The patient's own language. In a systematic review of 33 studies, 76% found at least one outcome better when patient and physician shared a language other than English.⁸

Measured in a working clinic. At The Wellness in London, which runs on wai every day, every clinician has 15 hours a week back, as published in the customer story.⁹

Where to start

Start with first appointments for one dietitian. In week one, build the assessment template with fixed fields for weight, height, BMI, waist-to-height ratio, background for the BMI threshold, the screening score and the goals, and measure the time from the end of each consultation to a signed note and GP letter. In week two, add the patient plan in the patient's language and recalls for reviews and repeat bloods, and count corrections to figures and units.

Then add follow-up and referral templates. Compare the workflow with the allied health guide and the endocrinology guide, see every profession on the specialties hub, and read how the scribe works on the wai Clinicians page.

Frequently asked questions