Chronic Kidney Disease Nutrition Therapy Note

Date: [Date]

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

Author Name and Credentials: [Name], [RDN / NDTR]

Referring Clinician and Referral Indication: [Referring clinician and reason for nutrition therapy]

Data Sources: [patient interview / caregiver report / EHR review / labs / food logs / other: specify]

Interpreter Services: [Language and modality] (Only include if interpreter services were used.)

Reason for Visit

• [Chief nutrition concern in patient-friendly terms with brief patient quote if helpful]
• [Patient-stated nutrition goals] (Use measurable language when available.)
• [Symptoms affecting intake: appetite changes, taste alterations, nausea, early satiety] (Only include if present.)
• [Diet history context: usual intake pattern / 24-hour recall / dialysis vs non-dialysis day pattern] (If unavailable, document why and alternative source used.)

Assessment

Kidney Disease Context

• [CKD stage and basis] (Per chart or estimated from most recent eGFR with date; do not introduce new diagnoses.)
• [Etiology] (Only if documented in chart.)
• [Dialysis status: not on dialysis / hemodialysis / peritoneal dialysis / home modality] (For dialysis patients: include schedule and residual urine output if relevant to counseling.)
• [Transplant status and time since transplant] (Only if applicable.)
• [Key CKD complications relevant to diet: hyperkalemia risk / hyperphosphatemia or CKD-MBD / volume overload / metabolic acidosis / diabetes management interplay] (Select those applicable.)
• [Relevant non-renal comorbidities shaping diet recommendations] (Do not assign new diagnoses; use chart-aligned phrasing.)

Food and Nutrition History

• [Usual intake pattern and meal timing] (Include dialysis vs non-dialysis day pattern if relevant.)
• [Protein sources and distribution across meals]
• [Sodium sources: processed foods, restaurant frequency, added salt habits]
• [Potassium pattern: high-potassium foods, salt substitutes, juices]
• [Phosphorus pattern: processed foods with additives, convenience foods, dairy]
• [Fluid intake pattern: beverages, volume, triggers]
• [Cooking skills, grocery access, food security, budget constraints]
• [Supplements and OTC products with nutrition impact]
• [Prior nutrition education, current knowledge, and readiness to change]

Anthropometrics

• [Current weight with date]
• [Weight trend with timeframe]
• [Height and BMI] (Include when relevant.)
• [Dialysis weights: pre/post and interdialytic gain pattern] (Only if applicable.)

Biochemical Data

(Include only labs needed to justify current intervention; provide dates and trend direction.)

• [Creatinine / eGFR / BUN]
• [Potassium]
• [Bicarbonate / CO₂]
• [Phosphorus]
• [Calcium]
• [Albumin]
• [A1c / glucose] (If diabetes present.)
• [Other pertinent labs]

Clinical Findings

• [Appetite and GI symptoms: nausea, vomiting, diarrhea, constipation, early satiety, dysgeusia]
• [Functional status affecting meal preparation: fatigue, mobility, cognition]
• [Nutrition-Focused Physical Exam findings] (Only if performed; document observed muscle/fat stores.)

Medications with Nutrition Impact

• [Phosphate binders: type, timing with meals, adherence]
• [Potassium binders: type, timing, adherence]
• [Diuretics relevant to fluid/electrolyte management]
• [Diabetes medications with hypoglycemia risk or meal timing implications]
• [Other nutrition-impact medications]

Estimated Needs

• [Energy target in kcal/day] (State method and weight basis: actual / adjusted / ideal body weight.)
• [Protein target in g/kg/day and total grams/day] (Include weight basis and rationale.)
• [Sodium goal with key strategies]
• [Potassium goal] (Only restrict if clinically indicated; note non-diet contributors when relevant.)
• [Phosphorus goal] (Focus on additive reduction; note binder timing if applicable.)
• [Fluid goal with behavioral strategies] (If indicated.)
• [Contraindications to standard restrictions] (Document reasoning if applicable.)

Nutrition Diagnosis

(Provide 1–3 prioritized PES statements. Prioritize by safety risk, then clinical impact, then patient readiness. Etiology should be modifiable through nutrition intervention.)

• [PES Statement 1: Problem related to Etiology as evidenced by Signs/Symptoms]
• [PES Statement 2] (Only if actionable.)
• [PES Statement 3] (Only if actionable.)

(If no actionable nutrition diagnosis exists, document: "No nutrition diagnosis at this time" with brief rationale.)

Intervention

Shared Goals

• [Goal 1: measurable outcome, timeframe, follow-up frequency]
• [Goal 2]
• [Goal 3] (Only if needed.)

Nutrition Prescription

• [Protein: g/kg/day and total grams with weight basis]
• [Energy: kcal/day]
• [Sodium: daily target with practical strategies]
• [Potassium: individualized approach] (Restrict only if indicated; if normal without clinical indication, omit numeric limit and note monitoring approach.)
• [Phosphorus: emphasize additive reduction and binder timing if applicable]
• [Fluid: daily goal with behavioral strategies] (If indicated.)

Education and Counseling

• [Topics covered: label reading, cooking methods, dining out, protein distribution, binder timing]
• [Methods used: teach-back, handouts, digital tools]
• [Patient response: comprehension, questions, engagement]
• [Barriers and supports: food access, budget, caregiver involvement]

Meal Planning

• [Practical guidance tailored to patient: sample day, swaps based on actual intake]
• [Binder integration with meals/snacks] (If applicable.)

(If no diet recall available, provide starter framework and note plan to individualize after recall is obtained.)

Coordination of Care

• [Communication to nephrology team]
• [Referrals made: social work, diabetes education, speech therapy]
• [Requests for updated labs or clarification of orders]

Monitoring and Evaluation

• [Dietary indicators: sodium sources, protein servings, additive avoidance, fluid tracking]
• [Anthropometrics: weight trend, interdialytic gains if applicable]
• [Labs to follow with expected draw date or frequency]
• [Symptoms to monitor: appetite, GI tolerance, energy]
• [Follow-up interval and modality]
• [Patient to bring: food log, labels, beverage counts, glucose records]

Safety and Escalation

(Include this section only when triggered; otherwise omit entirely.)

• [Red flags requiring medical escalation: inability to keep food down, rapid weight loss, volume overload symptoms, recurrent symptomatic hypo/hyperglycemia]
• [Contraindications to standard CKD restrictions with clinical reasoning]

Billing and Time

(Include only if required by organizational policy; otherwise omit.)

• [Total time spent per policy definitions]
• [Qualifying condition context for Medicare MNT if applicable]

Signature

[Name], [Credentials] | [NPI] (If used.)

[Date and time signed]