Sample Type / Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - 3
The patient is brought in by an assistant with some of his food diary sheets.
(Medical Transcription Sample Report)
The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.OBJECTIVE:
The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop. I encouraged him to continue all of that, as well as his regular physical activity.ASSESSMENT:
The patient is losing weight at an acceptable rate. He needs to continue keeping a food diary and his regular physical activity.PLAN:
The patient plans to see Dr. XYZ at the end of May 2005. I recommended that they ask Dr. XYZ what weight he would like for the patient to be at. Follow up will be with me June 13, 2005.
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