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Weight & Nutritional Counseling Template Executive
Summary The Partners
Pediatric Weight & Nutritional Counseling Template was designed to aid clinicians
in documenting delivery of exercise/nutritional counseling, and to improve
adherence to recommendations for assessing risks and behaviors that
contribute to childhood overweight status. This web site includes views of
each page of the template, as well as a sample clinical note. On the Partners
HealthCare System, this template exists within the notes section of the
electronic medical record (EMR). In
its current form, it is meant to be used by clinicians during a patient visit
to review weight and obesity risk factors. The template does not
provide the option of documenting other problems in detail. Note that only
relevant sections of the template need to be accessed for a given counseling
session. For example, if a physical examination is not performed during
the visit, there is no need to access this section; it will not be included
in the resulting note. Source This template
was developed under a grant from the Agency for Healthcare Research and
Quality (AHRQ), Improving Pediatric Safety and Quality with
Healthcare IT, in collaboration with the Partners HealthCare System Quality
Improvement Group, the Massachusetts General Hospital for Children, and
Partners HealthCare System Inc. Information Systems. Listed below are
the names of clinicians and experts who contributed to development of the
template. In addition, the LMR Pediatric Content Subcommittee and the
main LMR Content Committee reviewed the template, and approved it for use
with the Partners Longitudinal Medical Record (LMR). Contributors Timothy Ferris,
MD, MPH; Stephen Morgan, MD; Eric Poon, MD, MPH; James Perrin, MD; Alison
Hoppin, MD; Shelly Bernstein, MD; Peter Greenspan, MD; John Co, MD, MPH; Mark
Mandell, MD. Template
Example
Completed Clinical Note Vital Signs
These tools were
created using national, state, and local guidelines, and group consensus
regarding best practices. These guidelines, and their interpretation by
clinicians at Partners Healthcare System, may not represent the standard of
care across all regions or settings, and are not intended to be adopted or
applied without independent assessment of their suitability for a particular
setting. Moreover, guidelines change over time (for example, the age range
for children who should receive influenza vaccinations was recently extended
to 59 months). The rules and/or reminders contained within these templates
may need the addition or modification of certain items to ensure that they
remain consistent with current guidelines. Therefore, the tools included here
are intended only as examples or guides for the development of similar
templates in other settings. Partners Healthcare System and its affiliates
disclaim any and all responsibility or liability associated with the use of
the templates displayed here by third parties. |
