Functional Nutrition Consultation Note

Encounter Header

Note Type: [Initial Functional Nutrition Consultation / Follow-Up / Brief Check-In]

Date of Service: [Date]

Setting/Modality: [in-person / telehealth] (If telehealth, include patient physical location state: [State])

Clinician: [Name, credentials, license number and state if applicable]

Referral Source: [Ordering provider name and reason for referral, or self-referred] (Include only if applicable)

Relevant Medical Diagnoses: [Diagnoses with dates when known] (Label source: chart-confirmed or patient-reported)

Time Statement: [Total visit time in minutes] (Include only if required for billing; note that counseling/education comprised the majority of visit if applicable)

Chief Concern and Patient Goals

Chief Concern: [Patient's words, 1–2 brief quotes] (Include only if clinically relevant)

• [Patient goal 1]
• [Patient goal 2]
• [Patient goal 3]
• [Additional goals as applicable]

Success by next follow-up: [Brief statement tied to goals]

Nutrition Assessment

Subjective Assessment

(Document patient-reported information. Clearly distinguish allergies from intolerances/sensitivities, labeling severity and reaction type without upgrading terminology. For safety-critical fields—allergies, pregnancy status when planning restriction, eating disorder risk, baseline symptoms before elimination—use "Not assessed" or "Patient unsure" rather than leaving blank.)

• Food and Nutrition History: [Typical intake pattern including meal timing, frequency, weekday/weekend variation; diet recall method used; current dietary pattern and whether medically indicated or preference-based; dining out and cooking frequency; hydration; caffeine/alcohol patterns; prior interventions tried and response]
• Food Reactions:
  • Allergies: [Specific foods, reaction type, severity] (Patient-reported unless chart-confirmed)
  • Intolerances/sensitivities: [Specific foods, symptom type, timing] (Do not label as allergy)
• Functional Symptom Inventory: [GI symptoms (stool pattern, bloating, pain, reflux) with frequency, severity, timing; energy/fatigue patterns; sleep quality/timing; stress load; hunger/craving cues] (Document any red flags explicitly—unintentional weight loss, GI bleeding, dysphagia—and actions taken)
• Lifestyle Context: [Physical activity type/frequency; sleep schedule; work/caregiving responsibilities; social support around food]
• Barriers and Facilitators: [Access factors: budget, transportation, food availability, kitchen equipment; Skill factors: cooking confidence, meal planning, label reading; Time/energy constraints; Cultural/religious preferences; Emotional/behavioral factors]
• Readiness: [Stage of change; learning preferences; motivation and confidence ratings] (Include if useful for tracking)
• Supplements and Integrative Products: [Each product with dose, frequency, duration, purpose, whether patient-initiated or clinician-recommended, adverse effects, adherence issues]

Objective Assessment

(Document dates and sources for all data. Do not imply diagnostic certainty from non-diagnostic tests. Omit exam findings if no exam performed.)

• Anthropometrics: [Height, weight, BMI if relevant, weight trend and usual body weight] (Source: [clinic / home scale / device / chart]; Date: [date])
• Vitals: [Blood pressure, heart rate if available] (Source/date)
• Pertinent Labs: [Lab values with reference ranges, dates, sources: EHR/outside record/patient-reported]
• Medications with Nutrition Relevance: [Name, dose, timing if affects appetite, GI tolerance, or glycemia]
• Nutrition-Focused Physical Findings: [Relevant findings if assessed] (Omit section if not assessed)
• Screening Tools: [Tool name and results, e.g., malnutrition screening, eating disorder risk screen]
• Estimated Needs: [Energy, protein, fluid needs with method and assumptions] (Label explicitly as estimates)

Assessment Synthesis

[1–3 sentence narrative linking patient's goals to the most relevant assessment findings] (Distinguish conclusions based on estimation, pattern recognition, or patient report from confirmed data)

• Key drivers/contributing factors: [Behavioral, physiologic, access/environmental, and knowledge/skill factors]
• Nutrition risks identified: [Inadequate energy/protein, micronutrient gaps, overly restrictive patterns, other risks]

Nutrition Diagnosis

(Document the primary, most actionable nutrition diagnosis for this visit. Use PES format if your organization uses this terminology. Do not document medical diagnoses as nutrition diagnoses; for patient-reported medical diagnoses, use "patient reports prior diagnosis of..." or "symptoms consistent with... pending evaluation.")

Primary Nutrition Diagnosis: [Problem] related to [Etiology] as evidenced by [Signs/Symptoms]

Status: [new / ongoing / improving / resolved]

Secondary Nutrition Diagnosis: [Problem, etiology, signs/symptoms] (Include only if addressed during this visit)

(If no nutrition diagnosis applies, document: "No nutrition diagnosis at this time" with brief explanation)

Nutrition Intervention

Nutrition Prescription

• Overall dietary pattern target: [e.g., Mediterranean-style, consistent carbohydrate, high-fiber] (Include only when clinically relevant)
• Meal pattern: [Number and timing of meals/snacks; minimum structure expectations]
• Nutrient targets: [Calories, protein, fiber, sodium, added sugars, fluids as clinically relevant] (Note estimation method)
• Symptom-directed protocol: (Include only if elimination/reintroduction indicated)
  • Indication: [Rationale based on assessment] (State that food–symptom relationships are hypotheses to be tested)
  • Contraindications considered: [Pregnancy/lactation, eating disorder risk, pediatric growth, other] (State "None identified" if applicable)
  • Elimination phase: [Foods/ingredients removed; duration limit; allowed substitutions; nutrient adequacy safeguards]
  • Reintroduction phase: [Schedule; one-variable-at-a-time strategy; symptom diary method]
  • Personalization/maintenance phase: [Long-term liberalization plan]
  • Escalation criteria: [When to contact clinician if symptoms worsen or red flags emerge]
• Supplement plan: [Product, rationale, dose, timing, duration, monitoring plan, safety cautions, coordination with prescriber] (Include only if supplements recommended)

Education Delivered

• Topics covered: [List topics]
• Methods: [verbal counseling / demonstration / handouts / app guidance / other]
• Comprehension check: [Teach-back result or patient restatement of plan]
• Patient response: [Engagement level, key questions, concerns noted]

Counseling and Behavior Change

• Strategies used: [motivational interviewing / problem-solving / stimulus control / action planning / other]
• Barriers addressed: [Specific obstacles and solutions agreed upon]

Care Coordination and Referrals

(Include only if applicable)

• Communication to referring/primary provider: [Summary sent]
• Recommended labs/tests: [Request to ordering clinician with rationale]
• Referrals placed: [GI / allergy / behavioral health / eating disorder specialist / other with reason]
• Community resources provided: [Food assistance, cooking classes, support groups]

Monitoring and Evaluation

Goals

(Write SMART goals: specific metric, measurement method, tracking frequency, timeframe, success threshold)

• [SMART Goal 1]
• [SMART Goal 2]
• [Additional goals as applicable]

Monitoring Parameters

• [Dietary adherence and feasibility]
• [Symptom frequency, severity, triggers]
• [Anthropometrics if goal-related]
• [Relevant labs if available]
• [Readiness, confidence, barriers]

Follow-Up Plan

Recommended follow-up: [Timeframe]

Patient to track/bring: [Food logs, symptom scales, weight trend, lab results, questions]

Criteria for earlier contact: [Red flags: GI bleeding, significant unintentional weight loss, intolerable restriction, worsening symptoms, signs of nutrient deficiency]

Sign-Off

[Electronic signature, credentials, date/time]