Medical Record Documentation Form

Progress Notes
4/2/14
1000 Nate Nutrition Care Assignment
A
Pt. is a 28 y/o BM. Ht. 71 in. Wt. 385#. UBW 385#. %UBW 100%. Pt. dx:
T2DM. Estimated nutrition needs=2700 kcals/day, ~140 g protein/day. No
current diet followed. Nutritional status: obese. Current BMI of 53.7. Diet
hx: T2DM dx. for 10 years. Pt. reports hx. of yo-yo dieting. Pt. reports high
motivation level to lose weight and learn how to live with his T2DM.
D
Food and nutrition related knowledge deficit related to T2DM management
as evidenced by pt. reports lack of knowledge in managing T2DM and
nutrition basics.
I
Motivational interviewing to encourage pt. to set a goal. Pt. goal set at
increase exercise to 30 min, 5 X/week.
M &
E
Will f/u in 2 weeks to assess pt. compliance with goal, motivation,
questions and concerns. Will also provide education on nutritional
management apps for his smart phone, his nutritional analysis of his diet
recall, and refer him to recommended R.D.s.










Medical Record Documentation Form

Progress Notes
4/16/14
1000 Nate Nutrition Care Assignment
A
Pt. is a 28 y/o BM. Ht. 71 in. Wt. 385#. UBW 385#. %UBW 100%. Pt. dx:
T2DM. Estimated nutrition needs=2700 kcals/day or ~2200 to encourage
weight loss, ~140 g protein/day. Current diet order: Pt. reports currently
following Paleo diet. Nutritional status: obese. Current BMI of 53.7. Diet
hx: T2DM dx. for 10 years. Pt. reports compliance with goal set 2 weeks
ago. Pt. reports he is exercising even more than goal suggested. Pt. still
highly motivated to lose weight.
D
Food and nutrition related knowledge deficit related to T2DM management
as evidenced by pt. still reports lack of knowledge in managing T2DM and
nutrition basics.
I
Provide education on diet recall nutrition analysis. Provide education on
nutrition management apps for the smart phone. Provide nutrition
education on restaurant choices. Provide client with R.D. referrals for
future consultation as recommended by Maria.
M &
E
Will no longer be consulting with this pt.