Nutrition soap note example

What is a PES Statement, also known as a Nutrition Diagnostic Terminology Statement? A PES statement (or Nutrition Diagnosis Statement) is a structured sentence that describes the specific nutrition problem that you (the dietitian) is responsible for treating and working toward resolving, the cause/s of the problem and the evidence that this problem exists. Three components make up the PES statement : • • • The Problem (P)- the Nutrition Diagnosis The Etiology (E)- the cause/s of the nutrition problem (Nutrition Diagnosis) The Signs and Symptoms (S)- the evidence that the nutrition problem (Nutrition Diagnosis) exists. The PES statement is a structured sentence, hence has a specific format: Nutrition Diagnosis term (the nutrition problem) related to The Etiology (the cause/s of the problem or Nutrition Diagnosis) as evidenced by The Signs and Symptoms (the evidence that the nutrition problem or Nutrition Dx. exists). Example: Excessive energy intake, related to limited access to healthful food choices at work, as evidenced by estimated intake of energy (3000 calories /day) in excess of estimated energy needs (2400 calories/day) and BMI of 45. Lets look at its parts: The Problem (P) (Nutrition Diagnosis): is excessive energy intake. This is the specific nutrition problem that the Nutrition Intervention aims to treat and resolve. related to The Etiology (E) (the cause/s of the nutrition problem/Nutrition Diagnosis): is that the client has limited access to healthful food choices. Healthful (e.g. adequate amounts for fresh fruit and vegetables) food choices are not provided as an option. as evidenced by The Signs and Symptoms (S) (the evidence that the nutrition problem (or Nutrition Diagnosis) exists: the client’s estimated intake of energy is in excess of his estimated energy needs The client’s BMI equals 45 (obesity class III). Now let’s discuss each component of the PES statement. The Problem (P)- the Nutrition Diagnosis The Nutrition Diagnosis identifies the specific nutrition problem that the dietitian is responsible for treating and works towards resolving. The Nutrition Diagnosis comes from specific terminology as determined by the Academy of Nutrition and Dietetics. The Nutrition Diagnosis terms are classified into three categories: Intake: these diagnoses relate to intake and nutrition related problems (oral, enteral and parenteral nutrition). Intake diagnosis cover the areas including energy balance, fluid intake and nutrient intake. Examples: excessive energy intake, less than optimal intake of types of carbohydrate, inadequate calcium intake. Clinical: these diagnoses include medical or physical conditions that have a nutritional impact. The clinical category covers the areas of functional changes or impairments, biochemical changes (altered ability to metabolize nutrients) and weight. Examples: altered GI function, impaired nutrient utilization, overweight/obesity. Behavioral-Environmental: this category covers the nutritional problems associated with nutrition knowledge and belief (including attitude), physical activity and function (e.g. ability to self care) and food access and safety). Examples: undesirable food choices, physical inactivity and limited access to food or water. As a general rule (as with most rules there are exceptions) choose from Intake related Nutrition Diagnosis first, Clinical related Nutrition Diagnosis second and BehavioralEnvironmental last. Diagnosis should be specific to the role of dietitians. Behavioral-Environmental related Nutrition Diagnosis often fit better as the etiology (E) (the cause of the nutrition problem), and not the Nutrition Diagnosis itself. Remember the aim of your Nutrition Intervention is to resolve (ideally) the Nutrition Diagnosis. Make sure you check that your Nutrition Diagnosis is something that you as a dietitian can resolve (ideally) or improve. Some of the Behavioral-Environmental related Nutrition Diagnosis can be a bit tricky for a dietitian to solve. How to choose the correct Nutrition Diagnosis There are no right or wrong diagnosis choice (truly). Some choices may be better than others. Things to consider include: 1. Is it a nutrition based diagnosis, not a medical diagnosis (e.g. increased nutrient needs v.s. altered GI function)? 2. Is it the nutrition problem what your intervention aims to solve? Even though the client may have a particular nutrition problem e.g. inadequate fiber, if your intervention is not focused on increasing fiber intake i.e. your nutrition goals are around reducing saturated fat intake, leave that diagnosis for another time.