6 mo. Diet - Form? What things to Document?

[Band_Groupie 3]

Starting my 6 mo. diet on Monday with my PCP. They're not real supportive (sent me the "American Fare" 1200 & 1400 cal. diets with sample menus for a week, that's it). So I thought I'd put together a form for each visit to fill out (I've read that insurance doesn't just want a summary, they want to see that you've had education/dialogue about diet & exercise each time. Did you use a form or have suggestions on what needs to be documented besides my weight? Thanks all!

[ebonie1015 0]

Hi-

I know alot of insurance companies are different but here's what mine required with each visit:

1. Current weight and vitals (BP, pulse, etc.)

2. BMI

3. Description of weight loss plan that I was following (foods eaten, calories taken in, etc.)

4. Exercise (what, how much, how often, etc.)

5. Any discussions we had about my weight loss

6. My diagnosis had to be morbid obesity and it had to be listed on the note.

We could not discuss anything else other than my weight loss and progress or lack of. We also listed the number of the visit that I was on (i.e. Weigh-In #1, #2, etc.)

We made sure to have very thorough notes. It's better to have too much than not enough.

Hope I was helpful.

[Band_Groupie 3]

Thanks Ebonie! I'm starting to type up my form now. Did you handwrite the notes at your visit or did your PCP? Did you use a form or did the PCP just write things on their regular files/Dr. notes? Thanks!

[ebonie1015 0]

My PCP wrote the notes down on his regular office note pages. I have an older PCP who does not notate things as well as he should so I had to make sure that he wrote EVERYTHING down on those pages. I wanted to make sure those notes were as thorough as possible so that BCBS did not have to come back with any questions. :rolleyes2: Each visit had its own set of notes but we always made sure that all the elements were there.

Also, in the end, you will probably have 7 months of visits instead of 6. The initial visit + 6 consecutive weigh-ins. I ended up with 8 visits just to be on the safe side.

Edited November 10, 2008 by ebonie1015

[Band_Groupie 3]

Here's the form I used. It's a combination of the ones I've received and input here. My PCP said I don't need to do the daily log, she's never had insurance ask for it, so I'll be taking that off. *I took out some lines for writing, but you'll get the idea...insurance wants to see that you are being EDUCATED on more than just diet, so have them take good notes (Bottom section-we discussed my family history this month and how important that is to be aware of, and I typed a list of my family history to include).

DIET & EXERCISE PLAN FOR PATIENT: _____________________________ DOB______________

Visit #: __________ Date: ______________

Current Weight lbs.: __________

- GOALS ACHIEVED FROM _____/_____/_____ :

- Patient Self Assessment:

• Nutrition: _____________________________________________________
  

• Exercise: ____________________________________________________
  

• Sleep: ___________________________________________________
  

• Accountability: _______________________________________________________
  

- GOALS FOR NEXT MONTH:

• Nutrition:
  
  • Pt. to Follow ____________ Calorie Diet
    
  • Fluid: No Caffeine, No Carbonation, No Calories, Between meals only
    
  • Quality: Emphasize Protein, Low Sugar, Low Fat
    
  • Regularity: 3 meals per day, Eat every 4-5 Hours, No grazing, Slow meal down to 20-30 min.
    

  [*]Exercise:

  • Pt. to Exercise at least ______________ Min. per Week
    

• sleep
  
  • Pt. to Achieve 7-9 Hours per Night
    

  [*]Accountability:

  • Keep Food/Activity/Sleep Log
    
  • Support
    
  • Education
    
  • Stress Reduction
    

- COMMENTS ON PATIENT’S PROGRESS:

__________________________________________________________________________

- OBESITY HEALTH EDUCATION/GOALS-Post surgery, behavior changes, history, comorbidities, etc.:

___________________________________________________________________________

MD Signature

____________________________________________________

Edited November 12, 2008 by Band_Groupie

[ebonie1015 0]

The is what they are looking for. I had most of the same elements as well. They were just written on the doctor's progress notes. Just make sure that everything is documented. Better to have too much info than not enough.