Nutritional Progress Notes. Objectives. After this presentation, you will be able to: State the descriptive words for the acronym SOAP Give a brief description of the meaning for each word in the acronym SOAP Write a progress SOAP progress note from a case study. What is a SOAP Note?.
Nutritional Progress Notes
After this presentation, you will be able to:
Information provided/spoken by patient, family, or other person.
Factual and reproducible observations.
Summary of dietitian's professional nutrition diagnosis or clinical thoughts.
Describes the scope of Treatment and contains the action plan and prognosis.
S: works second shift, eats two meals a day, before/after shift; usually eats in fast food restaurants (fried foods, burgers, ice cream) for lunch and dinner. Does not add salt to foods. Takes blood pressure 2x/day. Activity: Plays volley ball on weekends
O: 34 y.o. female; last menstrual period = 01/05/2006; iron level= 12.3; history of hypertension x 2 years; blood pressure = 130/85 for last four readings; height = 5ft. 3in; weight: 205 lb; BMI=36.
A: obese; hemoglobin level normal; excessive sodium intake (NI-5.10.2) related to frequent use of fast food meals as evidenced by diet history. Blood pressure high/normal. Low physical activity.
P: Reviewed DASH diet. Identified foods to pack from home to eat during lunch/dinner. Discussed non-food rewards to purchase with money saved from not eating out when weight and B/P goals are reached. Encouraged more activity to facilitate weight loss. Next appointment = 30 days from today.
Your second appointment for the day is with a 25 year old Chinese male. He states he was told by his doctor that his cholesterol is high and he should to “eat better” but he is confused as to how to do that. He hands you a paper with the following labs on it: height = 67”; weight = 200#; blood pressure = 120/80; total cholesterol = 150 and LDL levels= 160.