ICD 9 Code/s:
Site of visit
Complaint/Reason patient stated for visit:
Pt. Visit: (New or Follow-Up)
Any conversation that is related to nutrition, nutrition diagnosis, nutrition concerns. This could
involve discussion of any barriers to adequate nutrition. If patient discussed information from
any physician or other medical personnel, you write that the patient stated that medical personnel
told the patient that…. (whatever was claimed).
Mention any nutrition-related advice you suggested for patient. Document whether you
recommended that patient see medical personnel for concerns or continued treatment related to a
particular medical-related issue/concern.
Age, height, weight, gender, BMI, BF
Estimated caloric needs:
BMR male: 655 + (9.6 x weight kg) + (1.8 x height cm) - (4.7 x age in years)
655 + (9.6 x 104.5 kg) + (1.8 x 154.94 cm) - (4.7 x 24 yrs) = 1824.29
TEE: (XXXX) BMR x 1.2 Activity Factor = X calories
This section can be confusing. Only write what you assess the issues to be. Other
information would be either in Subjective or Plan.) Include assessment based on BMI;
stage of change.
E.g. Patient will need ongoing support and reinforcement of goals. Weight has been a lifelong
struggle, so will need to understand the extent of the commitment required to attain a healthy
lifestyle. Needs to increase number of healthy snacks throughout their day; fruit or vegetable
with a healthy fat.
Problem: ………. (as related to…)
Etiology: ……… (as evidenced by…)
Signs/Symptoms: BMI of (E.g.) and diet history