Preoperative Nutrition Clearance Note (Bariatric Surgery)

Date: [Encounter date]

Author: [Name and credentials]

Referring Surgeon: [Surgeon name]

Bariatric Program: [Program or health system name]

Planned Procedure: [sleeve gastrectomy / RYGB / duodenal switch / other], [Planned surgery date / not yet scheduled]

Reason for Visit: [Brief purpose of encounter]

Clearance Determination

Clearance Status: [Cleared / Cleared with Conditions / Not Cleared]

Conditions or Barriers:

• [Condition or barrier]

(Include only when clearance is conditional or not granted. Be explicit and action-oriented. Omit section if fully cleared without conditions.)

Key Readiness Findings:

• [Readiness finding summarizing objective preparedness]

(Include 3-5 brief bullets.)

Clearance Statement: [Scoped clearance statement qualifying clearance as limited to nutrition factors and any contingencies]

Assessment

Program Pathway Stage: [Initial evaluation / Final clearance / Re-clearance]; Supervised Visits Completed: [Number completed of required total]; Food Logs: [Received and reviewed / Received, not yet reviewed / Not received]

Anthropometrics:

• Height: [Height with units]
• Current Weight: [Weight with units] [measured today / patient-reported]
• BMI: [BMI]
• Highest Adult Weight: [Value with units / patient-reported / not available]
• Program Start Weight: [Value with units and date / not available]
• Recent Weight Trend (3–6 months): [Losing / Stable / Gaining], [approximate magnitude]
• Pre-op Weight Goal: [Required / Not required]; Status vs Target: [On track / Not on track / Unknown]

Relevant Medical Conditions:

• [Condition with nutrition relevance]

(Include regimen if applicable; note risks during calorie restriction such as hypoglycemia for diabetes.)

Dietary Pattern Assessment:

• Meal Frequency and Timing: [Summary]
• Protein Sources and Consistency: [Summary of typical sources and textures]
• Snacking/Grazing: [Pattern and frequency]
• Sugar-Sweetened Beverages: [Type and quantified intake]
• Carbonation and Caffeine: [Intake and frequency]
• Alcohol: [Type, amount, frequency]
• Restaurant/Fast-food Frequency: [Frequency]
• Trigger Foods or Disordered Eating Patterns: [Description if present]
• Synthesis: [Brief statement on whether current pattern suggests elevated postoperative risk]

(Document nonjudgmentally; base on objective or clearly reported data.)

Hydration Assessment:

• Daily Fluid Volume: [Estimated total with units] [measured / patient-reported]
• Drinking Technique: [Sips vs gulps, straw use, separation of liquids from solids]
• Beverage Choices: [Water, zero-calorie, caffeine, others]
• Barriers to Adequate Intake: [Barriers identified]

Micronutrient Status:

• CBC with indices: [Date and result / not on file / pending]
• Iron studies including ferritin: [Date and result / not on file / pending]
• Vitamin B12: [Date and result / not on file / pending]
• Folate: [Date and result / not on file / pending]
• Vitamin D: [Date and result / not on file / pending]
• Fat-soluble vitamins and trace minerals: [Date and result / not on file / pending / not indicated]
• Other relevant labs: [List with dates and results]
• Identified Deficiencies: [Deficiency and severity]; Treatment Initiated: [Yes / No]; Recheck Timing: [Timeframe]
• Labs Pending or Not Obtained: [List with plan to obtain]

(Include fat-soluble vitamins A, E, K and trace minerals for malabsorptive procedures.)

Current Supplement Use:

• Multivitamin: [Product, dose, frequency]
• Calcium: [Type, dose, frequency]
• Vitamin D: [Dose, frequency]
• Vitamin B12: [Route, dose, frequency]
• Iron: [Form, dose, frequency]
• Other: [List]
• Adherence Barriers: [GI intolerance / cost / access / other / none identified]
• Post-op Form Tolerance: [Able to tolerate chewable or liquid / Uncertain]

Education Status:

• Post-op diet stages and texture progression: [completed / partially completed / not started]
• Protein-first principle and daily targets: [completed / partially completed / not started]
• Hydration strategy and separation from solids: [completed / partially completed / not started]
• Lifelong vitamin/mineral supplementation: [completed / partially completed / not started]
• Avoidance of concentrated sweets and dumping risk: [completed / partially completed / not started]
• Recognition of dehydration and deficiency warning signs: [completed / partially completed / not started]
• Label reading and product selection: [completed / partially completed / not started]
• Teach-back Results: [Patient demonstrated understanding / Areas needing reinforcement]
• Education Timeline: [Topics completed today] | [Topics completed previously] | [Topics remaining]

Psychosocial and Access Factors: [Food insecurity, transportation, health literacy, interpreter needs, support system, substance use concerns, or other factors relevant to nutrition readiness]

(Include only if relevant; use neutral, factual language. Omit if none identified.)

Diagnosis

Readiness Determination: [Ready / Ready with Conditions / Not Ready] — [One-sentence rationale linked to objective findings]

Active Nutrition Diagnoses:

• [Problem] related to [Etiology] as evidenced by [Signs/Symptoms]

(Use PES format; limit to 2-3 diagnoses. If no active nutrition diagnosis: "No active nutrition diagnosis at this time; focus is perioperative education and prevention.")

Intervention

Preoperative Diet Plan:

• Diet Type: [LCD / VLCD / Program-specific liver-reduction diet / Not required]
• Duration: [Start date] to [End date]
• Macronutrient Emphasis: [High protein, low added sugar, low refined starch, avoid alcohol]
• Diabetes Considerations: [Coordinate medication adjustments with prescribing clinician; monitor for hypoglycemia]

(Include diabetes considerations only if applicable. Document explicitly if no pre-op diet required.)

Protein Plan:

• Daily Protein Target: [Target g/day] — [Rationale]
• Protein Supplements: [Acceptable products and schedule]
• Behavioral Tactics: [Protein-first at meals, slow eating, meal frequency, portion guidance]

Hydration Plan:

• Daily Fluid Goal: [Goal in ounces and liters]
• Technique: [Small frequent sips throughout day; avoid drinking with meals; wait interval after eating]
• Beverage Guidance: [No carbonation; limit caffeine; avoid sugar-sweetened beverages]
• Contingency Instructions: [Actions if unable to meet fluid goals or signs of dehydration occur]

Micronutrient Supplement Regimen:

• Bariatric Multivitamin: [Product/form, dose, frequency]
• Calcium Citrate: [Total daily dose] divided into [number] doses, separated from iron
• Vitamin D: [Maintenance dose / Repletion dose with duration]
• Iron: [Elemental dose, frequency] (with vitamin C if indicated)
• Vitamin B12: [Oral / sublingual / IM], [dose and frequency]
• Deficiency Repletion: [Specific protocol with recheck timing]
• Thiamine Safety Note: Patient educated to seek prompt evaluation if prolonged vomiting or very poor intake occurs.

Education Delivered Today: [Topics covered, materials provided, teach-back results, patient questions addressed, engagement level]

(If not delivered today, state reason and reference prior completion.)

Care Coordination: [Communication sent to surgical team regarding clearance status]; [Referrals placed]

(Omit if no coordination actions taken.)

Monitoring and Evaluation

• Follow-up Schedule: [Next RD visit date or timeframe]
• Tracking Methods: [Food logs / protein and fluid checklist / weight checks]
• Lab Follow-up Plan: [Labs to be rechecked and timing]
• Conditional Clearance Metrics: [Specific measurable items required before surgery]

(Include conditional clearance metrics only if clearance is conditional.)

Red Flags Requiring Escalation: Inability to tolerate fluids, persistent vomiting, dizziness or confusion or neurologic symptoms concerning for thiamine deficiency, signs of dehydration. [Additional program-specific red flags]. Patient instructed to contact care team or seek urgent evaluation if these occur.

Patient Understanding: Patient verbalized understanding of plan; questions answered.

Signature: [Author name and credentials]

(If information is not available from the encounter, document as pending or not available rather than omitting. Link missing required elements to conditional clearance status. Do not infer adherence or deficiency status without documented objective basis. Label patient-reported data as such.)