Chronic Kidney Disease Medical Nutrition Therapy Note

Date/Time: [Encounter date; start–stop times or total face-to-face minutes]

Patient: [Patient name and relevant identifiers]

Provider: [Dietitian name and credentials (e.g., RDN, LD)]

Visit Type: [initial MNT / follow-up/reassessment / dialysis nutrition review]

Referral: [Referring clinician and clinical indication / referral not documented]

Mode: [in-person / video / phone] (For telehealth, include patient and provider locations and note telehealth consent obtained.)

CKD Status

(Provide a concise renal snapshot. If CKD stage or dialysis status cannot be confirmed, explicitly state "not documented" and note what data was used instead.)

• CKD G-stage: [G-stage (e.g., G3a, G4, G5)] with [eGFR and date] (State "CKD stage not documented" if unavailable.)
• Albuminuria category: [A1/A2/A3 with UACR and date / not documented]
• Dialysis status: [not on dialysis / HD / PD / post-transplant]
  • (If HD) Schedule: [days and shift]; Target dry weight: [kg]
  • (If PD) Modality: [CAPD/APD]; Regimen: [exchange volumes, dextrose/icodextrin]
  • (If transplant) Transplant date/status: [date/status]
• Volume/BP considerations: [Volume status, edema, BP trends impacting sodium/fluid goals] (Only include if documented.)
• Renal-relevant medications: [Phosphate binders, potassium binders, diuretics, diabetes medications with hypoglycemia risk, vitamin D analogs/calcimimetics] (Only include if documented.)

Assessment

Patient-stated goals and chief nutrition concerns: [1–2 sentences summarizing goals and primary concerns; include brief direct quotes if helpful; note symptoms affecting intake such as appetite change, nausea, taste alterations]

Anthropometrics:

• Height: [cm or in]; Current weight: [kg] (date); BMI: [kg/m²]
• Weight used for calculations: [kg] [actual / adjusted / dry / post-HD] (Rationale: [brief rationale])
• Recent weight change: [kg and % change over defined interval]
• Fluid status: [edema, interdialytic weight gain, signs of fluid overload / none documented]

Pertinent renal labs: (Include dates; flag abnormal values. Prioritize kidney function, electrolytes, CKD-MBD markers, nutrition proxies. Include dialysis adequacy markers if available. Note missing labs and steps taken to obtain.)

• Kidney function: [eGFR, creatinine, BUN]
• Electrolytes: [K, Na, CO₂, Mg as relevant]
• CKD-MBD: [Phosphorus, calcium, PTH as relevant]
• Nutrition proxies: [Albumin, A1C if diabetes]
• (If dialysis) Adequacy: [Kt/V, nPCR as available]

Dietary intake patterns: (Summarize typical pattern; focus on drivers of sodium, potassium, phosphorus, protein adequacy, fluids; include carbohydrate pattern if diabetes; note food access considerations if relevant.)

• Protein: [Primary sources and approximate intake; estimated g/day or g/kg/day if feasible]
• Sodium exposures: [Processed foods, restaurant frequency, added salt]
• Potassium drivers: [Salt substitutes, juices, large high-K portions]
• Phosphorus sources: [Additives, processed meats, dark colas]
• Fluids: [Total intake/day; IDWG if on HD]
• Diabetes-related: [Meal timing/CHO pattern; hypoglycemia history] (Only include if applicable.)

Estimated nutrition needs: (State guideline or protocol informing targets, especially if differing from standard ranges.)

• Energy: [kcal/day] (≈ [kcal/kg/day])
• Protein: [g/day] (≈ [g/kg/day]) [non-dialysis CKD / HD / PD / post-transplant]
• Sodium: [mg/day]
• Potassium: [mg or mEq/day / individualized based on labs]
• Phosphorus: [mg/day / focus on additive avoidance]
• Fluid: [L/day or individualized plan]

Diagnosis

(List 1–3 prioritized nutrition diagnoses using PES format. Prioritize immediate safety, then protein-energy wasting risk, then progression/adherence factors. Only include diagnoses supported by documented evidence.)

Nutrition Diagnosis 1: [Standardized nutrition diagnosis term] related to [Etiology: actionable root cause] as evidenced by [Signs/Symptoms: dated objective data, intake specifics].

Nutrition Diagnosis 2: [Term] related to [Etiology] as evidenced by [Signs/Symptoms]. (Include only if supported.)

Nutrition Diagnosis 3: [Term] related to [Etiology] as evidenced by [Signs/Symptoms]. (Include only if supported.)

Intervention

Nutrition prescription: Energy [kcal/day]; Protein [g/day] ([g/kg/day]); Sodium [mg/day]; Potassium [individualized]; Phosphorus [mg/day or additive focus]; Fluid [L/day or individualized]

Counseling focus: (Limit to 2–4 actionable changes. Emphasize substitutions over blanket restrictions. For hyperkalemia, address salt substitutes and large portions before broad produce limits; for hyperphosphatemia, focus on additive identification and binder timing; for sodium/volume, prioritize packaged and restaurant foods.)

• [Actionable change #1]
• [Actionable change #2]
• [Actionable change #3] (Optional)
• [Actionable change #4] (Optional)

SMART goals: (Link to diagnoses.)

• [Goal 1]
• [Goal 2] (Optional)
• [Goal 3] (Optional)

Care coordination: [Communication to nephrology regarding diet changes affecting labs or medications; referrals made (social work, diabetes education, community resources)]

Monitoring and Plan

(For each nutrition diagnosis, specify monitoring parameters, timeframe, and success criteria.)

• Diagnosis 1: [Parameters to monitor] | Timeframe: [interval] | Success criteria: [measurable targets]
• Diagnosis 2: [Parameters] | Timeframe: [interval] | Criteria: [targets] (Include only if applicable.)
• Diagnosis 3: [Parameters] | Timeframe: [interval] | Criteria: [targets] (Include only if applicable.)

Follow-up: [Planned interval and modality]; Patient to bring: [recent labs, food records/labels, glucose logs, dialysis run sheets as relevant]

Safety-net guidance: [When to contact nephrology promptly, e.g., persistent vomiting, severe hyper-/hypoglycemia, rapid weight change, symptomatic hyperkalemia, marked edema/dyspnea]

Electronic Signature: [Name, credentials, date/time]