Guest guest Posted January 4, 2012 Report Share Posted January 4, 2012 I am the only RD at my office and fairly new to bariatric surgery also so I hope what I have been using is right! But the three main ones I have been using are 1. Food and nutrition knowledge deficit r/t... 2.) Excessive caloric intake r/t.... 3.) Increased protein needs r/t... I am interested to see everyones responses to see if I am on the same page! Meaghan MS, RD/LD > > Hello All, > We recently converted to documenting all of our notes in an electronic medical record. The format prior to this did not correlate with the nutrition care process. > I am finding that I am using the same diagnoses with patients and was curious what most of you are using as a dx for post operative patients. > Any suggestions would be greatly appreciated. Thank you! > LaFleur RD, LD > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 5, 2012 Report Share Posted January 5, 2012 I am one of two RD's in our bariatric office and we are currently in the same process of converting over to NCP. We were just discussing this this morning.... We seem to be using Altered GI function AEB alteration in GI tract structure/function r/t RYGB/Sleeve/AGB as well as Obesity AEB BMI>35 r/t excessive energy intake and physical inactivity. These both seem to be things that are going to be ongoing problems. The obesity will eventually be resolved (hoepfully) but it seems that the Alt GI fx will always be a "problem" we were discussing whether or not we have to always document that on every f/u. Thoughts? From: edwardsmeaghan <edwardsmeaghan@...> Sent: Wednesday, January 4, 2012 4:07 PMSubject: Re: nutrition care process I am the only RD at my office and fairly new to bariatric surgery also so I hope what I have been using is right! But the three main ones I have been using are 1. Food and nutrition knowledge deficit r/t... 2.) Excessive caloric intake r/t.... 3.) Increased protein needs r/t... I am interested to see everyones responses to see if I am on the same page!Meaghan MS, RD/LD>> Hello All,> We recently converted to documenting all of our notes in an electronic medical record. The format prior to this did not correlate with the nutrition care process.> I am finding that I am using the same diagnoses with patients and was curious what most of you are using as a dx for post operative patients. > Any suggestions would be greatly appreciated. Thank you!> LaFleur RD, LD> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 5, 2012 Report Share Posted January 5, 2012 you still need to include your previous dx's in your follow up notes you just do not write the whole thing out again, you would just wtire the dx part for example: Nutrition dx: Altered GI function - remains valid Obesity - remains valid, partially valid, or no longer valid you can always add new dx's at the follow-ups but from what I am aware its not neccesary. If the dx is no longer valid, the next note you write for them you no longer have to include it. Hope this helps! Meaghan MS, RD/LD > > > > Hello All, > > We recently converted to documenting all of our notes in an electronic medical record. The format prior to this did not correlate with the nutrition care process. > > I am finding that I am using the same diagnoses with patients and was curious what most of you are using as a dx for post operative patients. > > Any suggestions would be greatly appreciated. Thank you! > > LaFleur RD, LD > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 5, 2012 Report Share Posted January 5, 2012 I have found the ADA Bariatric Pocket guide extremely helpful for the nutrition care process. I have attached a few examples from the book that we use commonly. I believe I heard they are in the process of updating it. The book breaks it down into pre-surgery and post which is helpful. I have never attached a document and posted before so feel free to email me directly if you cannot access it. Kadlubar, MS, RD, LDBaylor Weight Loss Surgery CentersGrapevine: 2020 W Hwy 114, Ste 180, Grapevine, TX 76051Irving: 1901 N Mac Arthur Blvd., Irving, TX 76051Phone: 817-305-5063 Fax: 817-305-5069www.baylorhealth.com/grapevineweightloss This e-mail may contain confidential and/or privileged information. This information is intended only for the use of the individual(s) and entity(ies) to whom it is addressed. If you are the intended recipient, further disclosures are prohibited without proper authorization. If you are not the intended recipient (or have received this e-mail in error) please notify the sender immediately and destroy this e-mail. Any unauthorized copying, disclosure or distribution of the material in this e-mail is strictly forbidden and possibly a violation of federal or state law and regulations. Baylor Health Care System, its subsidiaries, and affiliates hereby claim all applicable privileges related to this information. 1 of 1 File(s) Bariatric PES Statement Examples.docx Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 12, 2012 Report Share Posted January 12, 2012 I primarily use: *Overweight/Obesity RT Caloric Intake/Expenditure Imbalance AEB BMI___ *Food and nutrition related knowledge deficit RT No prior exposure to current diet OR Incomplete knowledge of current diet AEB Verbalization of no knowledge of diet OR Verbalization of questions about diet Dana Schaub MS,RD,LD Clinical Dietitian Specialist on @ Singing River Health System and South Mississippi Surgical Weight Loss Center DanaPearson@... From: LaFleur <jlod2@...>" " < > Sent: Wednesday, January 4, 2012 2:48 PMSubject: nutrition care process Hello All, We recently converted to documenting all of our notes in an electronic medical record. The format prior to this did not correlate with the nutrition care process. I am finding that I am using the same diagnoses with patients and was curious what most of you are using as a dx for post operative patients. Any suggestions would be greatly appreciated. Thank you! LaFleur RD, LD Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 12, 2012 Report Share Posted January 12, 2012 .....but that is for pre-op pts. Dana Schaub MS,RD,LD Clinical Dietitian Specialist on @ Singing River Health System and South Mississippi Surgical Weight Loss Center DanaPearson@... From: Dana Schaub <dancindrpea@...>" " < > Sent: Thursday, January 12, 2012 2:27 PMSubject: Re: nutrition care process I primarily use: *Overweight/Obesity RT Caloric Intake/Expenditure Imbalance AEB BMI___ *Food and nutrition related knowledge deficit RT No prior exposure to current diet OR Incomplete knowledge of current diet AEB Verbalization of no knowledge of diet OR Verbalization of questions about diet Dana Schaub MS,RD,LD Clinical Dietitian Specialist on @ Singing River Health System and South Mississippi Surgical Weight Loss Center DanaPearson@... From: LaFleur <jlod2@...>" " < > Sent: Wednesday, January 4, 2012 2:48 PMSubject: nutrition care process Hello All, We recently converted to documenting all of our notes in an electronic medical record. The format prior to this did not correlate with the nutrition care process. I am finding that I am using the same diagnoses with patients and was curious what most of you are using as a dx for post operative patients. Any suggestions would be greatly appreciated. Thank you! LaFleur RD, LD Quote Link to comment Share on other sites More sharing options...
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