Tackling an unfamiliar electronic health record (EHR)

For many dietitians, learning a new electronic health record (EHR) is one of the most challenging parts of starting a new role. Whether a new dietitian, a dietitian starting a new job, or a consultant dietitian, it’s almost guaranteed that an EHR will be a part of the job. The time of paper charting is practically obsolete. While EHRs are meant to improve efficiency and communication, they can also feel like a huge hurdle when stepping into a new role.   

Let’s take a practical approach to feeling confident in using any EHR, even when lacking experience in a specific system. We’ll start with what to cover during an interview for a new role, what to do on the first day of a new job (with or without training), and how to ask for help, all while staying compliant while figuring out the unfamiliar EHR.  

What to know about an EHR before starting a new job 

Before even logging into a new EHR, it helps to go into it with the right expectations. Every system is different. Some are more user-friendly than others, and some are very confusing at first. It’s important to understand that most employers do not expect you to know their system right away. If you go in expecting to feel a little uncomfortable at first, it takes the pressure off.  

The reality: It’s not just about the EHR 

It’s true that every system looks different. Tabs are in different places, and documentation sections vary, but the role of the clinical dietitian remains the same despite the variances in EHRs. Continue to focus efforts on assessing the patients, identifying nutrition problems, creating interventions, and monitoring progress. 

The Nutrition Care Process (NCP) provides a consistent framework that supports clinical decision-making, no matter what setting or what documentation system is in use. Keeping that process in the forefront of the mind, the EHR is just the tool that is used to chart it and keep things organized.  

How to handle the EHR question in an interview 

At some point in the interview process, it’s likely to be asked, “Do you have experience with our EHR?” And sometimes, the honest answer is no. Instead of seeing this as a disadvantage, this is an opportunity to showcase adaptability. Share the different systems utilized in past roles and highlight any experiences that prove the ability to learn a new system quickly. Ask if there are any training modules or hands-on training opportunities to learn their EHR. 

Being able to describe a patient care workflow and readiness to learn where one can find key patient information within the EHR highlights the ability to work well within a new charting system. Consider sharing an example from previous work that showcases the importance of accurate and clear documentation, as this is consistent no matter what EHR system is in use.  

Your first day: What to focus on 

Walking into a new role with an unfamiliar EHR can feel overwhelming, especially if training opportunities are minimal. Instead of trying to learn everything at once, narrow your focus to what matters most initially. 

Learn where to find: 

• Patient diagnoses and pertinent medical history 
• Lab results 
• Anthropometrics and weight history 
• Allergies 
• Medication administration record 
• Current diet and other active nutrition orders 
• Where nursing documents intake, such as meal/snack percentages, oral nutrition supplements, fluids, and nutrition support administration  
• Where to read previous dietitian documentation 
• Where and how to document assessments and notes   

If you are unsure where something belongs, use a free text or general note section if available. It’s better to capture your clinical thinking in the chart than to leave something out because of being unsure of where to put it. There will be the opportunity to refine where things go as the EHR becomes more familiar. 

It’s unnecessary to understand every tab, every function, or every feature right away. In fact, trying to do that will only slow things down. Focus on getting comfortable with the basic workflow first. Once you know where to find the most crucial information and where to document notes, everything else becomes much easier to build on. This may require keeping it simple in the beginning. Confidence builds from repetition instead of trying to get it all right on day one.  

A simple EHR tip that can help right away 

One simple strategy that can help, especially in the beginning, is to use a basic assessment template outside of the EHR. This can be printed out or handwritten and individually formatted. Having these written notes from chart review and the patient interview may prove helpful when sitting down to navigate documentation in the EHR.  

Early on, this practice can help bridge the gap between patient interaction and documentation. This also aids in staying more present with patients, instead of attempting to document everything into the EHR in real time. It allows focus to remain on the interview and assessment first, and then organization of documentation to come later.  

How to ask for help 

One of the most important parts of learning a new EHR is knowing how to ask for help. It’s easy to feel like one should already know what to do, especially for experienced clinical dietitians. But the truth is, every system is different. Many EHRs are customizable, so experience with a system doesn’t guarantee expert proficiency at a new facility.  

So, knowing who to ask and what to ask is just part of the process. The key is asking clear and focused questions to get the answers you need quickly. Instead of saying, “I don’t understand this system.” Try asking, “Where do you usually find weight trends?” Or “Where should I document my nutrition care plan?”  Keep in mind, even if you don’t have another dietitian to ask questions onsite, other interdisciplinary team members often know the system well and can at least provide direction. Some facilities have super users: team members who know the EHR the best and can provide guidance and training when requested.  

Staying compliant while you’re learning 

While learning the ropes, keep in mind the most important thing for documentation is remaining compliant. This can feel a little intimidating at first, especially if you’re unsure where everything belongs. But the good news is, compliance does not mean you have to be perfect. Being compliant means being accurate, timely, and appropriate in documentation. Ensure access to the facility’s nutrition care policy and a good understanding of any regulations pertaining to the facility type.  

It helps to focus on a few key areas: 

• Documenting in the correct section of the chart 
• Completing notes within the timeframe outlined by policy or regulation 
• Including all relevant clinical information to support assessment and plan details 
• Avoiding copying and pasting information without reviewing it for accuracy 

Clear and accurate documentation is essential for continuity of care and communication between the healthcare team. Even if notes take a little longer in the beginning, taking time to do it correctly will build good habits and confidence as the EHR becomes more familiar. 

Final thoughts 

Taking on an unfamiliar EHR is just part of being a dietitian in today’s clinical environment. It can feel overwhelming at first, and slow down chart review and documentation in the beginning, but it won’t be that way forever.  

Remember, it’s unrealistic to know everything on day one. With more practice and experience in different systems, more confidence will build. Over time, what once felt like a barrier becomes just another part of the workflow. At the end of the day, EHRs are simply tools. The ability to think critically and use clinical judgment, assess patients, and provide meaningful care is what truly matters.  

Dietitians On Demand is a nationwide staffing and recruiting company for registered dietitians, specializing in short-term, temporary, and permanent-hire positions in acute care, long-term care, and food service. We’re dedicated to dietitians and helping them enhance their practice and excel in the workplace. Check out our job openings, request your coverage, or visit our store today!

References:  

The Nutrition Care Process (NCP). eNCPT, Academy of Nutrition and Dietetics website. Accessed March 29, 2026. https://www.ncpro.org/nutrition-care-process 

Electronic Health Records. Centers for Medicare & Medicaid Services website. Accessed March 29, 2026. https://www.cms.gov/priorities/key-initiatives/e-health/records 

Provider Interaction with the Electronic Health Record: The Effects on Patent-Centered Communication in Medical Encounters. Published February 24, 2015. Accessed March 29, 2026.  https://pmc.ncbi.nlm.nih.gov/articles/PMC4339111/