dietitian nutritionist documentation kit

I have prepared the ADIME progress note for your third visit with this patient, focusing on the improvement in A1c and the ongoing carbohydrate counting intervention.

Nutrition Clinical Note: Follow-Up Visit

Patient Identifier: [Patient Name/ID]
Date: October 24, 2023
Visit Number: 3
Clinician: [Clinician Name], RDN

A – Assessment
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Food/Nutrition History: Patient reports improved adherence to carbohydrate counting framework discussed in Visit 2. Consistent intake of 3-4 carb choices per meal. Reports better energy levels in the afternoon.

• Anthropometrics: [Weight/Height data from chart]
• Biochemical Data: A1c 7.8% (dated 10/20/2023), decreased from 8.2% (dated 07/15/2023).
• Medical Data: Type 2 Diabetes (E11.9).

Behavior Observations: Patient expresses increased confidence in reading food labels but notes difficulty with meal timing on workdays.

D – Diagnosis
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PES Statement: Inadequate Food and Nutrition Related Knowledge related to meal timing as evidenced by patient report of inconsistent eating patterns on workdays and fluctuating pre-dinner glucose levels.

I – Intervention
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Nutrition Education: Provided education on the impact of consistent meal timing on glycemic control. Reviewed strategies for packing balanced snacks for work.

• Nutrition Counseling: Used motivational interviewing to identify barriers to mid-day meal consistency.
• Coordination of Care: Will update referring PCP on A1c improvement and current MNT progress.

ME – Monitoring & Evaluation

• Indicators: Consistency of mid-day meal timing (self-report log); Pre-prandial glucose stability.
• Thresholds: Target 5/7 days of consistent meal timing before next follow-up.
• Next Visit: 4 weeks.

Billing Codes: 97803 (Individual MNT follow-up)

Next steps

• Review the PES statement to ensure it matches your clinical judgment.
• Insert specific anthropometric data from the patient chart.
• Provide the patient with a summary of the meal timing strategies discussed.