Case Study Josephine's Medical Record

Having the proper documentation is a very integral component of a Josephine’s medical record because it will provide information about the care that she needs, her current status as well as communicating to others as to how well they may facilitate to her care. Each nutrition counseling session must have the correct documentation within Josephine’s medical record at all times, and must include:
• Basic information such as her name, date of birth, weight, and height.
• Date of visit.
• Diagnosis (primary and secondary).
• Allergy information.
• Reason for visit.
• Current medications taken.
• Relevant history/identification and evaluation of risk factors.
• Assessment and rationale for treatment.
• Goals and Josephine’s progress towards goals.
• Signature and time spent (King & Klawitter, 2007).

• Does she feel any improvement within her overall well-being?
• How the relationship now with her parents is since her diet has changed?

I would also assess her previously set goals by reviewing her chart since we started to see if there are any improvements or decline within her weight, or lab values.

Obstacles that could alter her success from reaching her realistic goals include:
• Fear of disobey her parents by consuming their unhealthy meals.
• Feeling guilty throughout the day whenever she consumes fried foods.
• Consuming one meal per day.
• Unexplained weight gain within 5 years.

I would assist her beyond these obstacles by implementing the following:
• Provide education to her about the importance of consuming the right kinds of carbohydrates, proteins and fats.
• Provide education to her about the effects of vomiting after consuming foods she shouldn’t.
• Provide education to her about consuming a nutritional supplement especially since she doesn’t consume a wholesome diet.
• Provide information to her about the importance of implementing various forms of physical activities on a daily