Name / Date / Time: John Doe / 7 March 2025 / 10:07 AM
Reason for Referral/Presenting Complaint/Diagnosis: Referred for nutritional assessment due to recent diagnosis of Type 2 Diabetes and concerns about weight management.
A - NUTRITION ASSESSMENT
Age: 45
Height: 175 cm
Weight: 85 kg
BMI: 27.8
Estimated Energy Needs: 2000 kcal/day, calculated using the Mifflin-St Jeor equation.
Estimated Protein Needs: 75 g/day, based on 0.8 g/kg body weight.
Other (specify): Fluid needs estimated at 2.5 litres/day.
Client History: John has a family history of diabetes and hypertension. He is currently on metformin and has a sedentary lifestyle. He lives alone and has limited social support.
Food/Nutrition-Related History: John follows a high-carbohydrate diet with frequent consumption of sugary snacks. He has a preference for fast food and reports low vegetable intake. He is independent in feeding but has not adhered to previous dietary advice.
Anthropometric Measurements: Waist circumference: 102 cm.
Biochemical Data, Medical Tests and Procedures: - HbA1c: 8.2% - Fasting glucose: 9.5 mmol/L
Physical Exam Findings: Mild muscle loss observed in upper arms, no signs of nutrient deficiencies.
Assessment, Monitoring and Evaluation Tools: Mini Nutritional Assessment (MNA) score: 11/14, indicating risk of malnutrition.
Comparative Standards: Dietary recommendations based on ADA guidelines for diabetes management.
D - NUTRITION DIAGNOSIS
PES Statement(s): Excessive carbohydrate intake related to lack of knowledge about diabetes management as evidenced by high HbA1c levels and dietary recall.
Etiology Category: Knowledge, Behavior
I - NUTRITION INTERVENTION
Aims/Goals (SMART): - Reduce HbA1c to below 7% within 6 months. - Increase vegetable intake to 5 servings per day within 3 months. - Achieve weight loss of 5 kg in 6 months.
Goal Progress Evaluation: New goal identified
Nutrition Prescription: Prescribed a balanced diet with 45% carbohydrates, 25% protein, and 30% fats, with emphasis on whole grains and vegetables.
Details of Intervention/Plan
Food and/or Nutrient Delivery (ND): - Introduce whole grains and reduce sugary snacks.
Nutrition Education (E): - Educated on carbohydrate counting and reading food labels.
Nutrition Counseling (C): - Motivational interviewing to address barriers to healthy eating.
Coordination of Nutrition Care by Nutrition Professional (RC): - Referral to diabetes educator for further support.
Nutrition Intervention Encounter Context (IC): - Conducted in outpatient clinic setting.
M/E - NUTRITION MONITORING AND EVALUATION
Specific Indicators, Criteria and Time Frame: - HbA1c levels to be checked every 3 months. - Dietary recall to assess vegetable intake monthly. - Weight to be monitored bi-weekly.
NUTRITION MONITORING AND EVALUATION TERMINOLOGY DOMAIN
Food/Nutrition-related History (FH): - Parameter: Vegetable intake - Indicator for Success: 5 servings/day - Time Frame for Measurement: Monthly
Anthropometric Measurements (AD): - Ongoing weight monitoring
Biochemical Data, Medical Tests and Procedures (BD): - HbA1c levels
Physical Exam Findings (PD): - Monitor muscle mass and fat distribution
Assessment, Monitoring & Evaluation Tools (AT): - Use MNA at follow-up to reassess nutritional risk.
Name / Date / Time:
[Enter patient name, consultation date, and time] (only include if explicitly mentioned; use full names and exact time of documentation if recorded)
Reason for Referral/Presenting Complaint/Diagnosis:
[Briefly describe the reason for the referral or consultation, including relevant diagnosis or presenting nutritional concern] (include only if explicitly mentioned; should be written in full sentences as a brief summary)
A - NUTRITION ASSESSMENT
Age: [Enter patient’s age] (only include if explicitly mentioned in the transcript or records)
Height: [Enter height] (only include if measured or recorded)
Weight: [Enter weight] (only include if measured or recorded)
BMI: [Enter BMI] (only include if calculated or recorded)
Estimated Energy Needs: [Enter estimated daily energy requirements and method used to calculate] (include only if explicitly assessed)
Estimated Protein Needs: [Enter estimated daily protein requirements and method used to calculate] (include only if explicitly assessed)
Other (specify): [Enter any additional nutritional estimates, such as fluid needs or micronutrient targets] (include only if applicable and explicitly mentioned)
Client History: [Describe relevant medical history, medications, psychosocial context, cultural considerations, functional capacity, and social support] (write as a paragraph; include only if mentioned)
Food/Nutrition-Related History: [Describe dietary patterns, food preferences, allergies/intolerances, supplement use, feeding independence or challenges, previous dietary advice and compliance] (write as a paragraph in full sentences, include only relevant elements mentioned)
Anthropometric Measurements: [Include any additional body composition or physical measurements not already mentioned above] (include only if relevant)
Biochemical Data, Medical Tests and Procedures: [Describe results of recent labs, tests, or diagnostic procedures relevant to nutritional status] (list in brief bullet points or concise sentences as in the original format)
Physical Exam Findings: [Include NFPE findings, such as muscle or fat loss, hydration status, and any signs of nutrient deficiencies] (only include if observed or documented)
Assessment, Monitoring and Evaluation Tools: [Enter any screening or assessment tools used (e.g., MNA, SGA), and the outcomes] (include tool name and score or interpretation only if explicitly mentioned)
Comparative Standards: [Reference dietary or clinical standards used as benchmarks in this assessment] (include only if explicitly referenced or implied in the consultation)
D - NUTRITION DIAGNOSIS
PES Statement(s):
[Write one or more PES (Problem–Etiology–Signs/Symptoms) statements based on the assessment data] (use standardised format; only include if a diagnosis is made)
Etiology Category:
[Enter relevant etiology categories from the list: Beliefs/Attitudes, Cultural, Knowledge, Physical function, Physiologic metabolic, Psychological, Social personal, Treatment, Access, Behavior] (only include categories applicable to the identified etiology)
I - NUTRITION INTERVENTION
Aims/Goals (SMART):
[Define specific, measurable, achievable, relevant, and time-bound nutrition goals] (use bullet points for each goal; include target value, timeframe, and outcome subject)
Goal Progress Evaluation:
[Enter current progress status for each goal] ([Enter one of the following: New goal identified / Goal not achieved / Goal achieved / Goal discontinued / Some progress / Some digression])
Nutrition Prescription:
[Provide a clear and concise nutrition prescription, including diet type, energy and macronutrient goals, texture or fluid modifications if relevant] (only include if prescribed)
Details of Intervention/Plan [Remove any category below if not used]
Food and/or Nutrient Delivery (ND): [List specific changes to food provision or nutrient delivery]
Nutrition Education (E): [Summarise any education provided on food, nutrients, or health condition management]
Nutrition Counseling (C): [Summarise behavioural strategies, motivational interviewing, or goal setting]
Coordination of Nutrition Care by Nutrition Professional (RC): [Describe any coordination with other professionals or services]
Nutrition Intervention Encounter Context (IC): [Document setting/context of intervention if applicable]
(Include only relevant components; use brief bullet points under each subheading if needed)
M/E - NUTRITION MONITORING AND EVALUATION
Specific Indicators, Criteria and Time Frame:
[Describe which specific indicators will be tracked to monitor progress, how success will be defined, and when reassessment will occur] (list 3–5 key indicators only)
NUTRITION MONITORING AND EVALUATION TERMINOLOGY DOMAIN
(Only include domains relevant to monitoring and evaluation)
Food/Nutrition-related History (FH):
- Parameter: [Enter parameter to monitor]
- Indicator for Success: [Describe outcome criteria]
- Time Frame for Measurement: [Define when it will be reviewed]
Medication/Alternative Medicine Use (FH-3): [Only include if relevant]
Knowledge Belief Attitude Determination (FH-4): [Only include if relevant]
Behavior Determination (FH-5): [Only include if relevant]
Anthropometric Measurements (AD): [Include if ongoing measurements will be used to evaluate outcomes]
Biochemical Data, Medical Tests and Procedures (BD): [Only include if monitoring lab data]
Physical Exam Findings (PD): [Only include if physical signs will be used to evaluate progress]
Assessment, Monitoring & Evaluation Tools (AT): [Only include if formal tools are used at follow-up]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
