Community Health Services - RD Note

Reason For Referral: [Person who referred, their profession, reason for referral] Assessment: - [Client's personal history: medical, family, and social history (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Anthropometrics: height, weight, BMI, weight history, including changes and ideal body weight (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Biochemical data: lab results, medical test outcomes (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Nutrition-focused physical findings: muscle and fat assessment, fluid assessment, skin turgor (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Diet history: dietary intake, food preferences, food recall, food security (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Physical activity history and limitations (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Diagnosis: - [Nutrition diagnosis based on assessment data (only include if explicitly mentioned and insert relevant ICD-10 code) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [PES statement: Problem, Etiology, Signs and Symptoms (only include if explicitly mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Intervention: - [Nutrition prescription tailored to the client's needs and goals (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Food and/or nutrient delivery: any dietary changes, supplementation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Education on specific nutrition guidelines, physical activity, health behaviors (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Counseling: strategies to guide the client towards health priorities (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Coordination of nutrition care with other healthcare professionals if needed (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Monitoring and Evaluation: - [Progress evaluation: tracking physical activity, food intake, symptoms, lab values (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] - [Follow-up care: deciding if and when a follow-up appointment is needed (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.)