Sample Type / Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - 2
The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.
(Medical Transcription Sample Report)
The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.OBJECTIVE:
Weight today is 201 pounds, which is down 3 pounds in the past month. She has lost a total of 24 pounds. I praised this and encouraged her to continue. I went over her food diary. I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern. I encouraged her to continue all of this.ASSESSMENT:
The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. She needs to continue all this.PLAN:
Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.
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