Bariatric Surgery Nutrition Follow-Up (Post-Op)

Date: [date]
Provider: [name, credentials]
Procedure: [LSG / RYGB / BPD/DS / other]
Surgery Date: [date]
Time Post-Op: [e.g., 2 weeks / 6 weeks / 3 months / 6 months / 12 months]

Subjective

[Visit purpose and patient's primary concerns] (Open with one concise sentence describing the reason for today's nutrition follow-up and the main concerns.)

Diet Stage & Tolerance: [Current program stage] — [foods tolerated well]; [foods causing intolerance and reaction type]. [Eating mechanics: pace, portion sizes, chewing, liquid–solid separation]. (Summarize briefly; include specific patterns impacting tolerance.)

Intake: Protein [grams/day] from [food / supplements / both]; Fluids [oz or L/day]; Meal pattern [meals/day] and [snacks/day]; [Protein-first behavior: yes / no]. [Intake estimation method]. (Use quantified values; avoid qualitative descriptors like "good" or "improved.")

GI Symptom Screen: [Document presence or absence of nausea, vomiting, dysphagia/food sticking, abdominal pain, GERD symptoms, dumping symptoms, bowel changes, and hypoglycemia-like episodes. For symptoms present, include relevant details such as frequency, timing, triggers, and severity. For safety-critical symptoms (persistent vomiting, inability to tolerate fluids, neurologic symptoms, severe hypoglycemia-like episodes), note whether escalation to bariatric team occurred. If any symptom not assessed, document "not assessed" with reason.]

Supplement Adherence: [Current regimen with products, formulations, doses, frequency]. [Adherence estimate: missed doses per week]. [Barriers or side effects if present]. (If details unknown, note that patient will provide at next visit.)

Objective

Weight Trend: Pre-op [date]: [weight] (BMI [value]); Surgery day [date]: [weight]; Last visit [date]: [weight]; Today [date]: [weight] (BMI [value]). [%TWL or %EWL as used by program].

Labs: [Most recent relevant labs with dates and values; flag abnormalities. Note labs due, ordered, or pending.] (Do not use "WNL" without key values when deficiency risk is relevant.)

Exam Findings: [Pertinent findings: signs of dehydration, hair/nail/skin changes, neurologic findings, other relevant observations]. (Include only if exam performed and relevant; omit entirely for telehealth or if no exam done.)

Assessment

[Brief clinical synthesis integrating: stage appropriateness and tolerance; protein and fluid adequacy vs goals; key symptoms affecting intake; weight trajectory with supporting data; lab concerns and supplement adherence issues.] (Keep patient-reported details in Subjective; reserve interpretations and clinical judgments for this section.)

Nutrition Diagnosis (PES): [Problem] related to [Etiology] as evidenced by [Signs/Symptoms]. (Include 1-2 diagnoses only when intervention is warranted; prioritize by clinical severity.)

Plan

Diet Stage: [Current stage guidance]. [Criteria to advance]. [Fallback instructions if intolerance occurs].

Protein/Fluids: Targets — Protein: [grams/day], Fluids: [oz or L/day]. [Specific strategies to achieve targets if below goal]. [Red flags prompting urgent contact].

Supplements: [Regimen adjustments]. [Repletion plan if deficiency present: product, dose, duration, monitoring]. [Adherence interventions if needed].

Symptom Management: [Dietary modifications for active symptoms]. [Coordination with bariatric team or referrals as needed]. (Omit if no active symptoms requiring intervention.)

Education: [Topics covered and patient understanding]. (Keep brief.)

Follow-Up: [Next visit timing]. [Parameters to monitor]. [Triggers for earlier contact].