Micronutrient Deficiency Evaluation & Repletion Note (Post-Bariatric)

Date: [date of encounter]

Encounter Type: [in-person / telehealth]

Author: [clinician name and credentials]

Reason for Visit: [concise statement anchoring why now]

History

Bariatric Surgery Context: [procedure type: sleeve gastrectomy / RYGB / BPD-DS / adjustable band / revision / unknown]; [approximate surgery date]; [absorption-impacting complications if any]. (If procedure or date unknown, state explicitly and note plan to obtain operative records.)

HPI: [onset, trajectory, severity, functional impact of presenting symptoms—focus on neurologic, visual, hematologic, dermatologic, musculoskeletal, and GI symptoms relevant to micronutrient deficiencies]. (When thiamine deficiency or other urgent conditions suspected, explicitly document presence or absence of high-risk features.)

Current Supplementation: [multivitamin type and dosing; calcium form and dose; vitamin D; B12 route and dose; iron; other supplements as applicable]. (Include adherence details: missed doses per week, duration of nonadherence, administration technique, tolerance issues, access barriers.)

Diet and Contributors: [protein intake, food intolerances, alcohol use, hydration status, medications affecting absorption—include only factors relevant to the clinical picture]

Objective

Vitals/Weight: [current weight, BMI, weight change since surgery or last visit]. (If not obtained or telehealth, state explicitly.)

Exam: [pertinent findings—general appearance, oral mucosa/tongue, skin/hair/nails, neurologic assessment including gait/proprioception/reflexes as indicated, other relevant systems]. (Document exam limitations and reason if applicable.)

Labs: (Present as summary with test name, date, result, reference range, and brief interpretation. Show trends when multiple values available. Do not generate values for tests not obtained.)

• [Hematology/iron indices: relevant results with dates]
• [B-vitamins: B12, folate, MMA/homocysteine, thiamine as obtained]
• [Bone-mineral axis: 25-OH vitamin D, calcium, PTH, phosphorus as obtained]
• [Fat-soluble vitamins and trace minerals as obtained]
• [Other relevant labs with dates]

(If no recent labs available, state explicitly and outline plan to obtain.)

Assessment

(Prioritized problem list ordered by clinical severity. For each deficiency, include: confirmed vs suspected status, supporting evidence with dated labs and key symptoms, severity/complications, likely contributors, and coexisting deficiencies. Use hedged language when not lab-confirmed.)

[Problem 1]: [status: confirmed / suspected]; [key evidence with dated labs and symptoms]; [severity/complications]; [likely contributors]; [related deficiencies if applicable]

[Problem 2]: [as above, include only if additional issues explicitly discussed]

Plan

[Problem 1]:

• Repletion: [supplement name, dose, route, frequency, duration, target goal, special instructions including spacing/timing]
• Maintenance: [ongoing regimen after repletion, note if lifelong]
• Monitoring: [labs to recheck, interval, success criteria, escalation criteria]
• Diagnostics: [additional workup if indicated]
• Adherence interventions: [formulation changes, simplified schedule, alternative route, access solutions as needed]

[Problem 2]: [plan elements as above, include only if applicable]

Patient Education: [lifelong supplementation importance, correct administration technique, expected improvement timeline, return precautions: urgent neurologic symptoms, vision changes, severe weakness, inability to tolerate oral intake, persistent vomiting]

Follow-up: [lab recheck timing]; [next appointment timing and modality]; [responsible clinician/service for ongoing bariatric surveillance if patient lost to follow-up]

Safety Notes: (If thiamine deficiency suspected, document that treatment was not delayed for lab confirmation, and note chosen route and rationale. If treating folate deficiency, document that B12 status has been assessed.)

(If any information is missing—procedure type, surgery date, labs, or exam—state explicitly and include plan to obtain rather than leaving blank.)