Cardiometabolic Risk Nutrition Therapy Note

Date of Service: [date]

Provider: [name, credentials]

Encounter Type: [initial / follow-up]; [in-person / telehealth]; [individual / group]

Referral Source: [referring provider and indication / Self-referred / Not documented]

Total Time: [face-to-face minutes] (Include non-face-to-face care coordination time only if allowable and documented.)

Reason for Visit

[Patient's stated primary concern] (Use a brief verbatim quote if it meaningfully conveys motivation or barriers. Include clinical indications prompting nutrition therapy such as hypertension, dyslipidemia, elevated ASCVD risk, metabolic syndrome, prediabetes, or NAFLD. Do not infer goals from diagnoses—document what the patient actually stated.)

• [Session objective 1]
• [Session objective 2] (Include only if discussed.)
• [Session objective 3] (Include only if discussed.)

Assessment

Cardiometabolic Data: [BP with context and date]; [lipid panel values with date]; [weight and/or BMI with date]; [glucose/A1c with date if relevant]; [relevant medications]; [ASCVD risk % if available]. (Explicitly note key missing data, e.g., "No recent lipid panel; labs requested.")

Dietary Intake: [2–4 sentence summary covering sodium drivers, fiber sources, fat quality, added sugars/SSBs, and alcohol if relevant. Note cultural preferences, food access, and constraints affecting recommendations. Include only information explicitly elicited.]

Readiness & Barriers: [Readiness to change and confidence level]; [key barriers]; [strengths and resources]. (Keep concise and action-oriented.)

Nutrition Diagnosis

• [PES statement #1: Problem related to Etiology as evidenced by measurable Signs/Symptoms] (Prioritize by clinical impact and patient priorities.)
• [PES statement #2] (Include only if sufficiently supported by data.)
• [PES statement #3] (Include only if sufficiently supported by data.)

(If data are insufficient to support a diagnosis, note the limitation and specify what data will be obtained.)

Intervention

Dietary Pattern: [Named approach: DASH-style / Mediterranean-style / plant-forward / other] — [2–4 food-based priorities: foods to emphasize, foods to limit, practical swaps or skills]. [Modifications or contraindications if applicable.] (Tailor to patient preferences and constraints.)

SMART Goals:

• [Goal #1 targeting PES etiology] — [timeframe] — Confidence: [0–10]
• [Goal #2] — [timeframe] — Confidence: [0–10] (Include only if agreed upon.)
• [Goal #3] — [timeframe] — Confidence: [0–10] (Include only if agreed upon.)

Education & Coordination: [Topics covered]; [materials provided]; [communication to other providers]; [referrals placed]; [scope notes, e.g., medication changes deferred to prescriber]. (Document only what occurred.)

Monitoring & Follow-up

Indicators: [Behavioral process metrics (e.g., restaurant meals/week, fiber servings/day) and clinical outcome metrics (e.g., BP, lipids, weight) with baseline value, target, and monitoring method/timing for each. Distinguish behavioral from clinical metrics. If baseline is missing, prioritize obtaining it before setting a target.]

Follow-up Plan: [Recommended interval and modality]; [what patient should complete/bring: BP log, food records, labs]; [escalation criteria if applicable].