Nutrition SOAP note: (be sure to include how you would evaluate whether plan was effective)

Subjective:
Classmate states she was unable to follow pre-assessment guidelines and had breakfast (cereal and an orange) 2. 5
hours prior to appt.; states a pre-existing condition of well-controlled asthma; claims a pertinent family history of low
blood pressure; claims that she is lightly active; states she is currently using an albuterol asthma
inhaler and has no nutritional concerns; Pts general appearance is normal; pt. reports no GI problems

Objective:
Anthropometric - Age: 20 yo. female, Height: 54.75 (164.5 cm); Weight: 131 # (59.5 kg)
Elbow Breath: 5.9 cm; Wrist Circumference: 15.3 cm; Frame Size: Medium; Knee Height: 49.1 cm;
Est. Stature: 160.9 cm; Waist: 32 in.(81.3 cm); Hip: 38 in. (96.5 cm); Ratio: .84 (High-risk); MAC: 28 cm;
Est. Weight: 62.2 kg IBW: 123.8 # (56.3 kg); %IBW: 105.8%; BMI: 22 (normal); TSF: 38 mm;
TSF Percentile: >95th; Suprailium: 36 mm; Thigh: 32 mm; %BF: 37% (unhealthy -too high)
cAMA calculation: 14.0 cm; cAMA nomogram: 14.0 cm; cAMA percentile: <5th (wasted);
BIA (Tanita): 23.7% Fat; Est. BMD: .675 g/cm2; T-Score: .8 (normal)

Biochemical Triglycerides: N/A; Total Cholesterol: N/A; LDLc: N/A; HDLc: N/A;
Blood Glucose: 103 (normal, non-fasting); Hemoglobin: 13 g/dL (normal); Hematocrit: 38% (normal)

Clinical BP (Manual): 98/79; BP (Automatic): 91/58; Pulse: 69/minute

Dietary Est. Calorie Needs: 1878-2168 (1900-2200) kcals.; Average Calorie Intake: 2168 kcals.;
%Protein: 16% of daily kcals.; %Carbs: 53% of daily kcals.; %Fat: 35% of daily kcals.;
Nutrients to note (Below RDA or above 130% of the RDA): %Potassium: 74.1%; %Copper: 212%;
%Magnesium: 183.8%; %Phosphorus: 235.7%; %Selenium: 234.5%; %Zinc: 150%; %Vitamin A: 131%;
%Vitamin B6: 208%; %Vitamin B12: 245.8%; %Vitamin D: 26.7%; %Vitamin E: 153.3%;
%Vitamin K: 131%; %Folate: 164%; %Riboflavin: 154.5%; %Niacin: 150%; %Choline: 68%

Assessment:
Patient has minor imbalances in daily intake of the Food Groups (Over in Grains and Fruit; Under in Dairy,
Protein, and Vegetables).

Patient is deficient in Vitamin D.

Plan:
Intervention Provide My Plate My Wins Daily Checklist and explain/demonstrate (with current food
record) the importance of meeting daily recommended servings within food groups, Provide
recommendation for daily Vitamin D supplement and being more active outdoors

Goals Become more conscious of food groups balance. Have patient fill out Daily Checklist 2x a week for 3 weeks
to consciously build a habit and then on the 4th week fill out a 3 day food record (including supplement
compliance) and return for follow-up.

Monitor/Reassess Will reassess the food record to see if positive change has taken place, will reassess
intervention tool and determine if it was effective for patient. Patient may make a follow-up appointment sooner if
needed.

Completed by (your name):______________________________________ Date: ___________________