Nutrition Counseling Note (Medical Weight Management)

Date of Service: [Date]

Clinician Name/Credentials: [Name, Credentials]

Visit Type: [Initial / Follow-up]

Encounter Type: [In-person / Video / Phone]

(Use person-first, non-stigmatizing language throughout. Document only what is explicitly provided.)

Reason for Visit

[Stated goals and focus for this visit] (1-3 sentences capturing the person's goals for this interval and today's focus areas. If goals are unclear, note that priorities were explored and document agreed focus.)

Assessment

Interval History: [Changes in eating pattern, hunger/appetite, GI tolerance, medication effects, symptoms impacting intake, lifestyle changes. For initial visits: baseline context including enrollment motivation and prior approaches tried.]

Anthropometrics: [Weight today with source labeled as measured or patient-reported; weight change since last visit and since program start; BMI. If weight unavailable, document why and note alternate progress indicators.]

Medical Context: [Pertinent conditions influencing today's plan. If none impact plan: "Reviewed—no changes impacting plan."]

Dietary Pattern: [Overall pattern summary; recall method used; meal timing/structure; estimated protein intake with distribution and barriers; estimated fluid intake with beverage types; hunger/satiety observations; meal planning context including food access. Label intake as "estimated" or "tracked" with source.]

Readiness & Barriers: [Confidence level; primary barriers; strengths]

Relevant Labs/Vitals: [Only if reviewed and used to shape plan—include test, date, value. If pending: "Awaited/ordered." If none: omit field.]

Supplements: [Current supplements with dose, frequency, adherence, side effects. If none: "No supplements reported."]

Nutrition Diagnosis

[PES statement(s)] (Format: "[Problem] related to [Etiology] as evidenced by [Signs/Symptoms]." Include only diagnoses meaningfully addressed this session. If no applicable diagnosis: "No nutrition diagnosis at this time" with brief rationale.)

Plan

Targets: [Protein target in g/day with current baseline and operationalization strategy; fluid target in oz or L/day with beverage strategy and baseline; additional program-specific targets as applicable]

Counseling Provided: [Meal planning strategies; hunger/satiety skills addressed; barrier → strategy pairs for problem-solving; supplement recommendations if applicable]

Materials Provided: [Handouts, tools, or trackers provided; note patient understanding confirmed via teach-back]

Goals (Next Interval):

• [SMART goal] (Include metric, frequency, timeframe; optional confidence rating 0-10.)
• [Additional SMART goal if applicable]

Monitoring Indicators: [Measures to reassess at next visit corresponding to diagnosis and goals—e.g., weight trend with source, protein/fluid intake estimates, hunger patterns, adherence to strategies]

Follow-Up: [Interval and modality; what person will track or bring to next visit]

Coordination: [Communication with prescriber, referrals, labs ordered] (Include only if applicable; otherwise omit.)