Dietitian Consultation Note

Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Shoulder stiffness and discomfort with overhead reaching, developing gradually over six weeks.

Assessment:
Movement restriction affecting daily activity.

Plan:
Agreed a graded home exercise programme and activity modification. Review progress in three weeks.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Dietician Consult Note

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
[Description of current nutritional concerns, symptoms, or reason for referral. Include relevant medical history, weight changes, appetite, gastrointestinal symptoms, and dietary restrictions.]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug, food, or environmental allergies]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]

Dietary History:
(hyphenated list)
- [Usual daily intake: meals, snacks, beverages]
- [Special diets or restrictions]
- [Food preferences or aversions]
- [Cultural or religious dietary practices]
- [Recent changes in diet]
- [Supplements or vitamins]

Physical Examination:
(hyphenated list)
- [Height, weight, BMI]
- [Relevant physical findings: e.g., signs of malnutrition, edema, muscle wasting]

Investigations:
(hyphenated list)
- [Laboratory results relevant to nutrition: e.g., albumin, electrolytes, glucose, lipid panel]
- [Other completed investigations]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary nutritional concern]

#) [Assessment as a numbered item if multiple issues]
(hyphenated list with each corresponding plan item on a new line)
- [Nutritional diagnosis or concern]
- [Dietary recommendations]
- [Education and counselling provided]
- [Plan for follow-up or monitoring]
- [Referrals to other providers if needed]
- [Return precautions or instructions]