Seen by Dietitian: Dr. Emily Carter
Date: 1 November 2024
Presenting Concerns:
* Patient seeking guidance on managing Type 2 Diabetes through dietary changes.
* Patient reports difficulty adhering to a balanced diet due to busy work schedule.
* Patient expresses interest in weight management.
Relevant medical history or test results:
* Diagnosed with Type 2 Diabetes in January 2023.
* HbA1c: 7.8% (prior to dietary changes).
* Current medications: Metformin 500mg twice daily.
Relevant family history:
* Father: Type 2 Diabetes.
* Mother: Hypertension.
Plan:
1. Goal 1: Reduce carbohydrate intake at each meal.
- Provide patient with a list of low-carbohydrate food options.
- Educate patient on portion control for carbohydrates.
- Recommend tracking carbohydrate intake using a food diary.
2. Goal 2: Increase consumption of non-starchy vegetables.
- Provide patient with a list of non-starchy vegetables.
- Encourage patient to include vegetables at each meal.
- Discuss strategies for incorporating vegetables into meals (e.g., adding vegetables to breakfast smoothies).
3. Goal 3: Increase physical activity.
- Discuss the importance of regular physical activity for blood sugar control.
- Recommend at least 30 minutes of moderate-intensity exercise most days of the week.
- Provide patient with resources for finding local exercise programs.
4. Goal 4: Improve understanding of food labels.
- Educate patient on how to read and interpret food labels.
- Provide patient with examples of food labels and practice exercises.
- Discuss the importance of checking for added sugars and hidden carbohydrates.
Anthropometrics:
* Clinic, 1 November 2024
- Weight: 85 kg
- Height: 170 cm
- BMI: 29.4 kg/m²
- Weight changes: Patient reports a 2kg weight gain in the last 6 months.
Discussion Points:
1. Carbohydrate Counting
- Explain the concept of carbohydrate counting.
- Provide resources for carbohydrate counting (e.g., apps, websites).
- Discuss how to adjust insulin doses based on carbohydrate intake (if applicable).
2. Meal Planning
- Provide patient with sample meal plans for diabetes management.
- Discuss strategies for meal planning, including grocery shopping and meal preparation.
- Encourage patient to create a weekly meal plan.
3. Healthy Fats
- Explain the importance of healthy fats in the diet.
- Provide examples of healthy fats (e.g., avocados, nuts, olive oil).
- Discuss the benefits of healthy fats for heart health.
4. Fibre Intake
- Explain the importance of fibre in the diet.
- Provide examples of high-fibre foods (e.g., whole grains, fruits, vegetables).
- Discuss the benefits of fibre for blood sugar control and digestive health.
Dietary History:
- Breakfast: Typically consumes cereal with milk and a piece of fruit.
- Morning tea: Often has a biscuit or a piece of fruit.
- Lunch: Usually has a sandwich with crisps.
- Afternoon tea: Sometimes has a chocolate bar.
- Dinner: Varies, but often includes pasta or rice with meat and vegetables.
- Supper: Rarely has supper.
- Food preferences:
- Likes: Fruits, vegetables, lean meats.
- Dislikes: Processed foods, sugary drinks.
- Allergies: No known allergies.
- Notes: Patient reports a busy work schedule and often eats meals on the go.
Additional Points:
* Patient expresses a strong desire to improve their health and is motivated to make dietary changes.
* Discussed the importance of regular blood sugar monitoring.
* Provided patient with a referral to a diabetes educator.
Follow-up Plan:
* Schedule a follow-up appointment in 4 weeks to assess progress and make any necessary adjustments to the plan.
Seen by Dietitian: [Dietitian full name] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as a single line.)
Date: [date of session] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as a single line.)
Presenting Concerns:
[reason for presentation] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as a single bullet point.)
[relevant medical history or test results] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as bullet points.)
[relevant family history] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as bullet points.)
Plan:
1. Goal 1: [description of goal] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- [action items for goal 1] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
2. Goal 2: [description of goal] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- [action items for goal 2] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
3. Goal 3: [description of goal] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- [action items for goal 3] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
4. Goal 4: [description of goal] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- [action items for goal 4] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
Anthropometrics:
[location and date of measurement] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as a single bullet point.)
- Weight: [weight in kg] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Height: [height in cm] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- BMI: [BMI in kg/m²] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Weight changes: [summary of weight changes] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Ultrasound muscle thickness measurement (if completed):
- Bicep: [measurement]
- Thigh (2/3rds): [measurement] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
Discussion Points:
1. [Topic 1] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- [key point 1]
- [key point 2]
- [key point 3]
2. [Topic 2] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- [key point 1]
- [key point 2]
- [key point 3]
3. [Topic 3] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- [key point 1]
- [key point 2]
4. [Topic 4] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- [key point 1]
- [key point 2]
5. [Additional topics] (Repeat format above as needed.) (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
Dietary History:
- Breakfast: [typical breakfast foods and habits] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Morning tea: [typical morning snack foods and habits] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Lunch: [typical lunch foods and habits] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Afternoon tea: [typical afternoon snacks] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Dinner: [typical dinner foods and habits] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Supper: [typical supper or late-night snacks] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Food preferences:
- Likes: [preferred foods]
- Dislikes: [disliked foods]
- Allergies: [list of known food allergies] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
- Notes: [additional details about eating habits, preferences, or nutrition concerns] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
Additional Points:
[any additional notes discussed such as referral to doctor, future interventions, barriers, or motivation] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as bullet points.)
Follow-up Plan:
[summary of follow-up arrangements, discharge instructions, or recommendation to re-refer] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as a single bullet point.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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, 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.)
