Signed nutrition note
Filed to chart · audit-locked · review only
Assessment
74 yo male on renal diet, followed for routine nutrition review. Weight stable at 79.4 kg over 30 days; meeting estimated energy and protein targets. Labs within expected range for CKD stage 3. No acute nutrition concerns this period.
Diagnosis (PES)
No active nutrition diagnosis. Continue current plan with monitoring appropriate to renal status.
Intervention
Maintain renal diet. Reinforced fluid restriction of 1,500 mL/day per nephrology and reviewed high-potassium foods to limit. No supplement indicated at this time.
Monitoring & Evaluation
Routine follow-up in 30 days; sooner if weight or labs shift. Continue monthly basic metabolic panel.
Intervention — edited
AI draft
Maintain renal diet. Consider fluid restriction if indicated. Reviewed high-potassium foods to limit.RD signed
Maintain renal diet. Reinforced fluid restriction of 1,500 mL/day per nephrology and reviewed high-potassium foods to limit.Monitoring — edited
AI draft
Routine follow-up in 2 weeks.RD signed
Routine follow-up in 30 days; sooner if weight or labs shift.The RD tightened a vague recommendation into a specific, sourced order and adjusted the follow-up interval — exactly the kind of judgment the signature captures.