This example shows how an electronic health record dietetics nutrition progress note template can use only free text. In this example the data is organized differently than by following the four steps of the Nutrition Care Process. Each healthcare organization can create their own customized template based on their organizational needs. See the tutorial video for additional explanation of the rationale for this type of template.
| Sections of the Nutrition Progress Note | Description of what would be included | Example of content |
| Nutrition Consultation For: | Describe the reason for the consultation, e.g. nutrition screening, nutrition assessment for malnutrition, follow-up on inpatient nutrition care, discharge diet consultation. This information is included so the rest of the healthcare team can determine WHY this progress note was written. |
IP Consult for Diabetic Gastroparesis, Low BMI |
| NUTRITION DIAGNOSIS | ||
| PES Statement(s) Problem, Etiology, Signs and Symptoms |
Provide one or more PES statements which identify the nutrition problems the dietitian is addressing. Note: beginning the entry with PES statement(s) enables the health care team to quickly identify the dietitian's focus. The team may not require information regarding the dietitian’s rationale however, if they do need additional information, they can read the detail of the entry. If the PES statement is influenced by Nutrition Focused Physical Findings these finding are a key support for the PES statement. If not, this information is positioned beneath the Nutrition Assessment Summary. |
Chronic Disease Related Malnutrition related to inadequate oral intake secondary to altered GI function as evidenced by gastroparesis with type 1 diabetes mellitus, 22% weight loss in 9 months, consuming less than 50% of estimated needs, moderate fat and muscle loss. |
| ESTIMATED NEEDS | ||
| Estimated Energy Needs (& Method of Estimation) | This section is used to describe estimated energy and nutrient needs for nutrition intervention | Estimated energy needs: 1820-2020 kcal/day (Mifflin St Jeor x 1.3 activity factor + 300-500 kcals for gradual weight gain) |
| Other (Specify) | Enter other nutrients of concern | Estimated protein needs: 66 gm/day (1.5 gm/kg) |
| Other (Specify | Enter other nutrients of concern | Estimated fluid needs: 1540 ml/day (35 ml/kg current body weight) or MD discretion |
| NUTRITION INTERVENTION | ||
| Nutrition Prescription | The dietitian enters the optimal nutrition prescription here. In some cases, it is the same as the Diet Order shown in the system. See information below that is auto-populated by the E.H.R content. | Modified carbohydrate diet, 2000 kcal, with 66 gm protein, 1540 ml fluid, small meals per day plus Commercial Beverage - Glucerna TID |
| Aims/Goals (SMART) | The dietitian enters relevant goals | Goal: Prevent or reduce nutrient deficiencies, preserve lean body mass and maintain/improve strength and energy |
| Detail of Intervention/Plan | In this section, the dietitian would enter the details of the nutrition intervention (usually using the eNCPT terms that reflect the activities. If the patient is hospitalized, then indicate whether the current diet order should be continued or whether there is a change needed. | Continue current modified-carbohydrate diet. Will send Commercial Beverage- Glucerna TID. Nutrition Education – Content Related Discharge and Transfer to Other Providers - Please enter outpatient referral to RD for further education needs on gastroparesis and weight gain. |
| RD Interaction Summary | This is a free text area for the dietitian to describe the nature of interactions with clients. This narrative section includes:
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Met with patient at bedside. Patient’s oral intake has reduced significantly since April. Advice on increasing calorie intake for weight gain provided. Discussed nutrition recommendations for gastroparesis. Patient encouraged tocontinue small, frequent meals, chew food well, sit upright following meals, avoid high-fat foods and beverages, limit bulky high-fiber foods and avoid night-eating. Advised to avoid CATS (caffeine, alcohol, tobacco, stress). Encouraged patient to sip whole milk in place of water and to try nutrition supplement drinks such as Glucerna (tolerated during admission). Writer performed NFPE. Provided patient withhandout on Gastroparesis Nutrition Therapy and High Calorie Drink Recipes. Is open to meeting with outpatient RD for further education. |
| Nutrition Assessment Summary | ||
| Personal Data: (DATA AUTO POPULATED FROM DEMOGRAPHICS) Diet Order: (DATA AUTO POPULATED FROM DIET ORDER) Consult Diagnosis: (DATA AUTO POPULATED FROM MD PROBLEM LIST) Patient/Client/Family Medical/Health History: (DATA AUTO POPULATED FROM PATIENT HISTORY) |
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| This is a free text area for the dietitian to describe additional Nutrition Assessment information. This may include detail of patient’s current hospital diet/pre-hospital diet intake, as well as Nutrition-Focused Physical Findings. | Food and Nutrient Intake - Consuming 20% of meals Patient History - Food Allergies: NKA (no known allergies) Medications - Calcium carbonate-vit D3, Heparin, Lantus, Reglan, Myostatin, Protonix, KCl in NS, K-dur. |
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| Anthropometric Measures | HT, WT, BMI AUTO POPULATED FROM E.H.R | Wt Readings from Last 10 Encounters: 01/02/19 44 kg (97 lb) (2 %)* 11/15/18 43.1 kg (95 lb) (1 %)* 10/13/18 43.5 kg (96 lb) (2 %)* 07/12/18 38.5 kg (84 lb 14 oz) (<1 %)* 07/12/18 38.1 kg (84 lb) (<1 %)* 04/04/18 56.3 kg (124 lb 1.9 oz) (48 %)* 03/14/17 54 kg (119 lb) (43 %)* * Growth percentiles are based on CDC (Girls, 2-20 Years) data |
| This is a free text area for the dietitian to provide additional information regarding the patient’s anthropometric measures. This may include reported weight history/trends, dry weight and weight change assessment. | No weight loss indicated prior to admission per nursing malnutrition screen. +12 lb in 6 months, however patient is still considered underweight. -27 lb in 9 months (22% weight loss - severe) Estimated body mass index is 17.74 kg/m² as calculated from the following: Height as of this encounter: 1.575 m (5' 2"). Weight as of this encounter: 44 kg (97 lb). BMI Less than 18.5 kg/m²: Underweight IBW: 110 lb (50 kg) |
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| Nutrition Focused Physical Examination | This section may be added as appropriate as separate section to document Nutrition Focused Physical Examination Findings | Nutrition Focused Physical Examination Appetite: Fair Chewing /swallowing issues: None Hand-grip strength: Undocumented Edema: None Last BM: Undocumented Braden Scale Score: 19. Braden Nutrition Score: 2. Skin assessment: no skin issues. The following observations help support a diagnosis of severe malnutrition per ASPEN guidelines. Patient exhibits 4 out of 6 clinical characteristics that support a diagnosis of severe malnutrition, i.e. decreased energy intake (consuming less than 50% estimated needs), weight loss (22% weight loss in 9 months), body fat loss (moderate subcutaneous fat loss in triceps region) and muscle mass loss (moderate muscle loss in deltoid and interosseous regions) |
| Biochemical Data, Medical Tests and Procedures (Select data to include) |
DIETITIAN SELECTS LABORATORY TESTS TO INCLUDE IN PROGRESS NOTE RELEVANT TO NUTRITION CARE | Would show historical blood glucose readings for past 8 months from MD office visits. |
| NUTRITION MONITORING AND EVALUATION | ||
| Categories of Monitoring and Evaluating Indicators | Have list of categories to choose from | Food and nutrition intake Anthropometrics Nutrition-focused physical examination Biochemical data. medical tests and procedures |
| Specific Indicators, Criteria and Time Frame What will you assess during follow-up consultations? |
Here, the dietitian enters the specific indicator, criteria to judge whether the intervention has been successful and when it will be re-measured. | Energy intake – achieve estimated needs, 2 days Diet tolerance – absence of diarrhea, stools as inpatient Weight Gain – slow gain of 0.5 lbs per week, each RD encounter Fasting glucose levels, labs as inpatient within normal parameters |
| YOUR NAME Registered Dietitian |
DATE: (AUTO POPULATE DATE AND TIME WHEN ENTRY WAS SAVED/SUBMITTED) Time spent with chart and patient ___enter minutes with patient/charting_______(Minutes) |
Student first name Last name Professional identifier Time spent with chart and patient 35 Minutes |
Updated February 18, 2019