Medical Specialty:
Diets and Nutritions

Sample Name: Dietary Consult - 2


Description: 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)


SUBJECTIVE: 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.

Keywords: diets and nutritions, food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food,