Sample Type / Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - 3
Description: The patient is brought in by an assistant with some of his food diary sheets.
(Medical Transcription Sample Report)
SUBJECTIVE: 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.
Keywords: diets and nutritions, weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food,