GI Disorder Nutrition Note

Date of Service: [Date]

Patient Name: [Full name]

Provider Name and Credentials: [Name, credentials]

Encounter Type: [Initial / Follow-up]

Referral Source: [Referring provider or clinic]

Modality: [telehealth video / telephone] (Only include if telehealth; include required location statements per site policy if applicable)

Reason for Visit

[Referral question or main concern; GI condition focus (confirmed / suspected / under evaluation); relevant inpatient diet order if applicable; patient's stated goals and priority symptoms] (1–3 sentences)

Nutrition Assessment

Key Findings Summary:

• Symptoms and hypothesized dietary drivers: [Symptom pattern and likely dietary contributors, framed as testable hypotheses with timing/latency when known]
• Current dietary pattern and restriction burden: [Typical pattern; notable exclusions/avoidances; cultural and food access considerations]
• Nutrition risks: [Weight change with timeframe; intake adequacy; micronutrient concerns]
• Readiness and barriers: [Motivation, capacity, competing demands, health literacy, constraints]

GI Symptom Profile: [Primary symptoms with onset, frequency, severity, timing relative to meals, and typical latency; stool pattern including frequency, Bristol Stool Form Scale type, urgency, straining, incomplete evacuation; nocturnal symptoms if present]

Red-flag screening: [Findings or "None identified"] (Include for initial visits or when symptoms have changed; document unintended weight loss, GI bleeding, persistent nocturnal symptoms, fever, anemia, age-appropriate cancer screening status. If not assessed and clinically relevant, state "Not available; recommended.")

Dietary intake and exposures: [Typical intake pattern; major exposures relevant to symptoms (dairy/lactose, gluten/wheat, fermentable carbohydrates, fiber type, fat load, caffeine, alcohol, sugar alcohols); fluid intake; food environment and accessibility if relevant]

Symptom–food correlation summary:

• [Suspected trigger]: Data source: [Diary dates / recall]; Typical dose: [Amount/form]; Latency: [Time to symptom]; Symptoms: [Specific symptoms]; Confidence: [high / moderate / low]; Confounders: [Overlapping foods, stress, medications, etc.]
• (Add additional triggers as needed)

Medical and surgical history: [Pertinent GI and non-GI history; procedures/surgeries; pelvic floor history if applicable]

Medications and supplements: [Current meds/supplements affecting GI function; recent changes]

Anthropometrics: [Height; current weight; BMI; usual body weight; weight trajectory with timeframe and percent change]

Pertinent labs/diagnostics: [Results with dates that impact nutrition care] (If unavailable and clinically meaningful, state "Not available; requested/recommended.")

Nutrition Diagnosis

• [Problem (nutrition diagnosis term)] related to [Etiology (modifiable driver)] as evidenced by [Signs/Symptoms (objective or subjective evidence)].
• [Second PES statement if applicable]
• [Third PES statement if applicable]

Nutrition Intervention

Selected intervention: [Chosen approach and rationale linked to assessment findings and patient goals; note shared decision-making]

Therapeutic diet plan:

• Approach: [Diet approach name]
• Restriction/Elimination phase: Start [Date]; planned end [Date]. Avoid: [Foods/components]. Emphasize/substitutions: [Allowed alternatives]. (Restriction phases are time-limited.)
• Reintroduction/Challenge phase: Start [Date or criteria]. Protocol: [One category at a time; dose escalation; washout period; stopping rules]. Recording: [How results will be logged; decision rules for tolerance].
• Personalization/Maintenance phase: Start [Date or criteria]. Include: [Tolerated foods/categories]. Limit: [Non-tolerated items with thresholds]. Ongoing strategies: [Meal pattern, fiber/fluid targets as relevant].

Adequacy and supplementation: [Identified nutrient risks due to intervention; mitigation strategy (food-based solutions, fortified options); supplements if indicated with indication, dose, duration, and coordination with managing clinician]

Education: [Topics covered; materials provided; patient understanding confirmed]

Care coordination: [Requested labs; referrals; communication with other providers]

Monitoring & Follow-up

Monitoring parameters:

• Symptoms: [Stool frequency/Bristol type; urgency; bloating/pain rating] — Target: [Target]; Tracking: [Method]
• Diet process: [Phase adherence; challenges completed; identified tolerances] — Target: [Target]; Tracking: [Method]
• Nutrition status: [Weight trend; intake adequacy; pertinent labs] — Target: [Target]; Tracking: [Method]
• Quality of life: [Sleep, energy, activity, functional participation] — Target: [Target]; Tracking: [Method]

Follow-up: [Timeframe]; Patient to bring: [Food/symptom diary; challenge logs; updated weight; labs]

Contingency plan: [When/how to contact clinic; actions for worsening symptoms; red-flag instructions per site policy]

Provider Signature: [Name, credentials]

Co-signature: [Name, credentials] (Include only if required by site policy)

Total face-to-face time: [Minutes] (Include only if time-based billing applies)