Reason For Referral
Dr. Emily Carter, GP, referred the patient due to concerns about unintentional weight loss and poor dietary intake.
Method of Visit
In-person visit with the client and her daughter present.
Consent obtained:
Consent for assessment and intervention was obtained from the client and her daughter.
Client's goal
Client's goal: To gain weight and improve energy levels. Daughter's goal: To learn how to prepare nutritious meals for her mother.
Assessment
Anthropometrics: Current weight 55 kg, height 165 cm. Recent weight loss of 5 kg over the past 3 months (8% of usual weight).
Relevant medications: Lisinopril 10mg daily, Metoprolol 25mg twice daily, and a daily multivitamin.
Relevant blood test results: Recent blood work shows low albumin and prealbumin levels.
Relevant medical history: Hypertension, history of a stroke, and dysphagia.
Diet history: Client reports consuming small portions of food, primarily soft foods due to swallowing difficulties. Fluid intake is adequate.
Social: Client lives with her daughter, who provides support with meals and medication reminders. The client also receives support from a home health aide three times a week.
Tools used for health or disease status or risk assessment, reassessment, monitoring and evaluation: Mini Nutritional Assessment (MNA) score of 18, indicating risk of malnutrition.
Etiology category: Altered GI function related to dysphagia.
Comparative standards: Compared to the client's previous weight and BMI.
Evaluation of progress towards nutrition-related goal(s) and resolution of a nutrition diagnosis: The client's progress will be evaluated based on weight gain, improved nutritional intake, and symptom management.
Nutrition Diagnosis:
Inadequate oral food/beverage intake related to dysphagia as evidenced by unintentional weight loss and poor dietary intake.
Nutrition Interventions:
Goal Planning: The client and her daughter will work together to achieve the client's goals of weight gain and improved energy levels.
Nutrition Prescription Planning: The client will be prescribed a high-calorie, high-protein diet with modified textures to accommodate her dysphagia. The plan includes small, frequent meals and snacks.
Food and/or Nutrient Delivery: The daughter will prepare meals, and the home health aide will assist with feeding if needed. The dietitian will provide a list of appropriate foods and recipes. Supplements will be provided as needed.
Education: The dietitian will provide education on the importance of adequate nutrition, the use of texture-modified diets, and strategies to manage dysphagia. Handouts on high-calorie, high-protein recipes will be provided. The daughter will receive education on meal preparation.
Nutrition Counseling: The dietitian will provide counseling to the client and her daughter on meal planning, food choices, and strategies to improve nutritional intake. The dietitian will collaborate with the client and her daughter to establish food and nutrition goals and action plans to foster client ability to self-care and promote health.
Coordination of Care: The dietitian will coordinate care with the client's GP and speech therapist.
Monitoring and Evaluation
Weight will be monitored weekly by the daughter. Symptoms will be monitored daily by the client and her daughter. Nutritional intake will be assessed weekly by the dietitian using a food diary.
Evaluation
Food and Nutrition-Related History Outcomes: The client's food and nutrient intakes, supplement use, knowledge and or beliefs or attitudes, behavior changes, food and supply availability, functional capacity, and client-centered measure will be evaluated.
Anthropometric Measurement Outcomes: Body weight change will be monitored.
Biochemical Data, Medical Tests, and Procedure Outcomes: Lab data will be reviewed.
Physical Exam Finding Outcomes: Findings from a physical exam, interview or health record will be reviewed.
Who is going to contact whom and by approximately when: The dietitian will contact the client and her daughter in two weeks to assess progress.
Reason For Referral
[referral source's name and profession, reason for referring to community dietitian] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Method of Visit
[in person or remote (phone or video), who is present at the visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Consent obtained: [Note if consent has been obtained] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Client's goal
[client's goals, caregiver's goals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment
[Anthropometrics: current weight, height, recent weight changes in kg, recent weight changes as a percent of usual weight over the time period specified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Relevant medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Relevant blood test results, relevant diagnostic tests and exams] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Findings from a physical exam, interview, or health record] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Relevant medical history, relevant procedure history, new diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Diet history - usual intakes, portion sizes, type and amount of fluid consumed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Financial - type and source of income, amount, adequacy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Social - informal supports such as spouse, children, friends or neighbors and formal supports such as community support workers (differentiate between private pay and subsidized), assisted living, or long term care. Frequency and reliability of visits.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[tools used for health or disease status or risk assessment, reassessment, monitoring and evaluation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[etiology category] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[comparative standards] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[evaluation of progress towards nutrition-related goal(s) and resolution of a nutrition diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Nutrition Diagnosis:
[problem] related to [etiology] as evidenced by [signs and symptoms]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Nutrition Interventions:
[Goal Planning - include client's stated goals and desired outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Nutrition Prescription Planning - include the rationale for choosing the customized care recommendations for this client] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Food and/or Nutrient Delivery - include details on how client will get access to food, formula, supplements, and fluids. Include details on meal delivery companies, pharmacy deliveries, shoppers or volunteers, home support workers providing meals and at what times, friends or family providing food, food bank access, and short-term nutritional supplements access] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Education - include the names of any handouts or literature provided, include the names of people receiving education, include details on cooking, modifying food textures, or providing tube feeds. Include knowledge imparted about client’s nutrition needs, nutrition sequelae from a medical condition, or swallowing difficulties] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Nutrition Counseling - include collaboration to establish food and nutrition goals and action plans to foster client ability to self-care and promote health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Coordination of Care - include consultation with referrals to, or coordination with other clinicians, health care providers, agencies, institutions or programs that assist in treating or managing nutrition-related problems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Monitoring and Evaluation
[Name of people doing the monitoring of which expected outcome such as weight, symptoms, how often and by what method] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Evaluation
[Food and Nutrition-Related History Outcomes - include food and nutrient intakes, supplement use, knowledge and or beliefs or attitudes, behavior changes, food and supply availability, functional capacity, and client-centered measure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Anthropometric Measurement Outcomes - include body weight change] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Biochemical Data, Medical Tests, and Procedure Outcomes - include lab data, tests, enteral tube replacement details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Physical Exam Finding Outcomes - include findings from a physical exam, interview or health record] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Who is going to contact whom and by approximately when] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[if the problem has been resolved or if it is no longer a nutrition issue or a client priority, then plan to close the referral and communicate this to the client and the referral source] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
