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Nutrition Care SOAP Note Example

The SOAP note documents the case of James Steiner, a 58-year-old male with hypercholesterolemia, who reports weight gain and excessive snacking, expressing willingness to lose 5% of his weight through dietary changes. His objective measurements indicate obesity and high cholesterol levels, leading to a diagnosis of obesity and suboptimal fat intake. The plan includes a goal of 15 lb weight loss over 6 months, a nutrition prescription of 2700 kcal/day, and a referral to a heart-healthy workshop.

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28 views2 pages

Nutrition Care SOAP Note Example

The SOAP note documents the case of James Steiner, a 58-year-old male with hypercholesterolemia, who reports weight gain and excessive snacking, expressing willingness to lose 5% of his weight through dietary changes. His objective measurements indicate obesity and high cholesterol levels, leading to a diagnosis of obesity and suboptimal fat intake. The plan includes a goal of 15 lb weight loss over 6 months, a nutrition prescription of 2700 kcal/day, and a referral to a heart-healthy workshop.

Uploaded by

viviandeto
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Documenting Nutrition Care: SOAP example

SOAP NOTE
Patient Name: James Steiner ID: 009821 Date/Time: 09/15/2018, 11:15 a.m.
Age: 58 Sex : Male Medical diagnosis: Hypercholesterolemia
Subjective
Patient reports excessive snacking at work, little exercise, recent weight gain of
10 lb in past year; willing to attempt 5% weight loss and dietary/lifestyle changes
to reduce LDL-C before trying statin medication
Objective
Height: 6 ft 1 in.; Weight: 268 lb
Total cholesterol: 288 mg/dL
LDL-C: 214 mg/dL; HDL-C: 48 mg/dL Triglycerides: 132 mg/dL
Documenting Nutrition Care
BMI: 35.4, obesity II
Waist circumference: 45 in.
EER: 2725 kcal
Diet order: Weight reduction; heart-healthy diet
Assessment
Abdominal obesity; dietary recall indicates ~3700 kcal intake per day and diet high in fat, saturated fat, trans fat
Nutrition Diagnoses: 1. Obesity related to excess energy intake of ~1000 kcal/day and physical inactivity as evidenced by
elevated BMI; 2. Less than optimal fat intake related to poor food choices as evidenced by elevated LDL cholesterol and
body weight
Plan
Goal: 15 lb weight loss over next 6 months; patient to walk 45 min/day
Nutrition prescription: 2700 kcal/day weight reduction with ~30% kcal from fat, 7% of kcal from saturated fat, minimal trans
fat
Initial education: discussed food portions, low-kcal foods, sources of saturated and trans fats, pre-planning meals and
snacks
Referral: Heart-healthy workshop on 9/22; patient to attend with wife
Follow-up visit: 10/15 (1 month); patient to bring 3-day food record and identify appropriate portions, saturated/trans fat
sources
Signature: Genevieve Johnson, M.S., R.D. Position: Dietitian, Nutrition Services

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