Weight Management & Nutrition Coaching Note

Date: [Date]

Encounter Type: [Initial / Follow-up; Individual / Group; In-person / Telehealth]

Provider/Credentials: [Provider name and credentials]

Patient: [Patient name or identifier]

Goals & Progress

[Patient-stated goals in their own words, including any timeframe] (Use person-first language. Quote short phrases when helpful.)

(For follow-up visits only; omit section for initial visits)

• [Weight change, date, and context] (Indicate measured vs. self-reported. If not obtained, note reason.)
• [Behaviors attempted and adherence since last session]
• [Facilitators, barriers, and what helped or didn't]

Assessment

(Summarize only content assessed; omit unassessed elements. Focus on patterns that inform the plan.)

• Eating pattern & structure: [Meal timing, frequency, consistency]
• Notable intake patterns: [Relevant findings: beverages, eating out, protein/fiber adequacy as discussed]
• Triggers & high-risk times: [Situational triggers and vulnerable times of day]
• Readiness & confidence: [Stage of change, confidence level, motivators and concerns]
• Related factors: [Activity, sleep, stress if relevant to plan]

Pattern synthesis: [1–2 sentence linkage of key patterns to main challenge]

Impression

[Brief working summary of weight-related challenge and top contributing factors] (Use person-first, non-stigmatizing language. Do not assign diagnostic labels unless established.)

[Safety considerations and escalation/referral if indicated] (Include only if concerning behaviors present: severe restriction, purging, syncope, uncontrolled psychiatric symptoms.)

Plan

Agreed behavior changes: (List 1–3 specific, measurable actions the patient will do. Include dose/frequency, timing, and start date.)

• [Behavior change 1]
• [Behavior change 2] (Include only if agreed.)
• [Behavior change 3] (Include only if agreed.)

Strategies discussed: [Self-monitoring approach, implementation intentions, environment changes, social support]

Education provided: [Key teaching points] — Patient understanding: [Demonstrates / Partially demonstrates / Needs reinforcement]

Referrals: [Type, purpose, and patient response] (Omit if none.)

Monitoring & follow-up: [Metrics to track and by whom] [Follow-up timing and format] [Data patient should bring to next visit]

Patient agreement: [Affirms / Modifies / Declines] (Document explicit agreement; summarize any adjustments requested.)

Billing/Eligibility: [Counseling time in minutes] [Eligibility elements if applicable] (Include only if required for billing.)