Diabetes Medical Nutrition Therapy (MNT) Note

Note Type: [Initial MNT / Follow-up/Reassessment MNT]

Date of Service: [Date]

Duration: [Total minutes]

Patient: [Patient name/identifier]

Dietitian: [Name, credentials]

Referring Provider: [Name]    Referral Date: [Date] (Required for Medicare MNT billing)

Primary Reason for Visit: [Brief statement of nutrition/glycemic concern prompting today's encounter]

Presenting Concerns & Patient Goals

[Chief nutrition/diabetes concerns (1–3 items)] (For follow-ups, include relevant changes since last visit.)

[Patient-stated goal(s) in their own words] (If not explicitly stated, summarize goal collaboratively set today.)

[Safety concerns identified: severe/recurrent hypoglycemia, symptomatic hyperglycemia, unintended weight loss, suspected disordered eating, pregnancy] (Include only if present; omit paragraph entirely if none.)

Nutrition Assessment

Diabetes Profile: [Type, duration, relevant complications/comorbidities impacting nutrition; current care team if known]

Glycemic Targets: [A1C goal; TIR/TBR targets if CGM user] (If targets not yet established, note need for prescriber coordination.)

Glycemic Data: [CGM: device, data period, sufficiency, average glucose, TIR, TBR <70, TAR, variability; pattern interpretation with meal-linked excursions and hypoglycemia timing/triggers] OR [SMBG: testing frequency, typical ranges by time of day, hypoglycemia frequency/patterns] (Use whichever is the primary data source; do not include both.)

Hypoglycemia Risk: [History of severe lows, awareness status, prevention behaviors, identified triggers] (Include for patients on insulin/secretagogues. If low risk with no episodes, state briefly.)

Medications: [Diabetes medications and insulin regimen with meal/timing relevance; GI side effects affecting intake; items requiring prescriber coordination]

Anthropometrics/Labs: [Height, weight, BMI, weight trend/goal; A1C with date; pertinent cardiometabolic labs] (If key data unavailable, note briefly.)

Dietary Pattern & Carbohydrate Strategy: [Meal timing/structure; carbohydrate approach (carb counting with targets / consistent carb plan / plate method / low-carb); carb distribution by meals/snacks; high-impact dietary drivers; food access/security considerations]

Lifestyle Factors: [Physical activity and exercise-related glycemic issues; sleep/shift work; stress patterns affecting intake/timing] (Include only if pertinent to nutrition plan.)

Nutrition Diagnosis

• [PES #1: Problem related to Etiology as evidenced by Signs/Symptoms] (Prioritize safety issues first.)
• [PES #2] (Then hyperglycemia patterns.)
• [PES #3] (Then weight/cardiometabolic concerns. Include 1–3 total.)

(If insufficient data to support diagnosis, note plan to obtain needed information.)

Intervention & Plan

Nutrition Prescription: [Individualized eating pattern; targeted carbohydrate distribution by meals/snacks; protein/fiber/hydration goals if addressed]

Counseling Provided: [Topics covered; methods used; materials provided; patient understanding/teach-back results]

Glucose Pattern Actions:

• [Actionable link between diet and glycemic pattern + specific behavior change patient will make]
• [Additional pattern-action links as applicable] (Include 2–4 total.)
• [Recommend prescriber review of specific item based on patterns] (Include only if coordination needed.)

Hypoglycemia Prevention: [Tailored prevention strategies; treatment education (fast-acting carb dose, re-check timing); CGM alert adjustments discussed] (Include only if applicable.)

SMART Goals:

• [Goal #1: Specific behavior + measurement method + timeframe + barrier/workaround if identified]
• [Goal #2]
• [Goal #3] (Include 1–3 goals.)

Care Coordination: [Referrals made/recommended; communication to referring provider]

Monitoring & Follow-up

Monitoring Indicators: [Key metrics to track with targets: TIR/TBR trend, fasting range, A1C, weight, behavioral adherence]

Data Sharing: [How patient will share data before next visit and timeframe]

Follow-up: [Planned interval and modality]

Escalation Criteria: [When to contact clinic urgently]

[Billing attestation: total face-to-face minutes; initial vs reassessment] (Include only if required by practice setting.)

Electronic Signature: [Name, credentials]   [Date/Time]