Lose It! This two-week phase is designed to jump-start your weight loss, so you may lose up to 6 to 10 pounds (2.7 to 4.5 kilograms) in a safe and healthy way. If she is not making any progress, she agrees to connect with Weight Watchers. Susan will send a progress note in 6 months regarding her weight. She is aware of the health hazards of obesity-including diabetes, knee osteoarthritis, and heart disease. She agrees to get a lipid and blood glucose check. She feels she can get her weight down to 250 over the next 12 months. Plan: Discussed the importance of a healthy diet and exercise. 294 BMI 42.3 BP 124/78 P-76Īssessment: Major health issue is obesity. Family history notes that an older sibling has weight issues and that Susan has a maternal aunt who developed breast cancer at age 51. She is in a monogamous relationship and is thinking that she would like to have a family. She does not smoke and has one alcohol drink a month. Susan has started to watch her intake of sugar. She does not exercise but is thinking about getting back to this. She realizes her weight is up from 3years ago but it has been a stressful time. She is taking vitamins but no prescription medications. Subjective: Susan is a 40 year old computer programmer who is here after a three-year hiatus from health care as she now has a job and health insurance. Patient plans to return in 2 months for follow-up appointment.Īnother example-CC: Here for an annual check-up daily to 20 oz., eating dinner at table 1 night per week.Īfter discussing patient preferences I referred to for additional follow-up. Used motivational interviewing to illicit change talk and established initial goals with patient, including: walking daily to mailbox, reducing soda from 40 oz. _ Weight Watchers _ TOPS _ CHIP _ Other (specify): _ Text FormatĪt-the-point example-Discussed weight, diet, exercise with patient in relation to health conditions. The patient expressed a desire for referral: _ Yes _ No We discussed referral to community resources for weight management: _ Yes _ No Template Format-I discussed health consequences of weight including (diabetes, knee OA, hypertension, heart disease, etc.). These models are provided as a "straw man" and clinics are strongly encouraged to discuss and refine according to local preferences and protocols. The two examples below (template and text format) provide learning models depicting how you might document brief counseling and referral for weight management. Determine a strategy for modifying existing templates or refining encounter text to capture the key elements.Įxample Chart Notes for your Clinic's UseĬhart notes are often structured based on personal preference and/or the formatting capabilities of your Electronic Health Record.Discuss if there are opportunities for improving documentation of screening, problems, brief counseling, and referrals.What do chart notes look like when you see a patient with weight issues?.What is the current format of your chart notes-do clinicians/staff tend to use text or templates?.Plan for "next steps" related to healthy lifestyle maintenance/change.Ĭonsider These Steps as You Refine the Documentation Process.Documentation of referral to external resource or that referral to resource was declined.Indication that brief counseling around diet, exercise, weight management occurred during the encounter (use motivational interviewing approach).Diagnosis/listing of weight management, obese, overweight in the patient's problem list (use the "appropriate" code determined by your practice). Ideally patients identified as overweight or obese (BMI > 25 30, respectively) would have the following documented in their chart at each visit: This worksheet is designed to help your clinic document brief counseling and referral for patients who experience challenges with weight management.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |