Integrating Primary Care Practices and Community-based Resources to Manage Obesity

Tool 7. Documenting the Conversation in Your Charts

Documenting and Tracking Weight Management Discussions—How to Capture Brief Counseling and Referral in Your Chart Notes

This worksheet is designed to help your clinic document brief counseling and referral for patients who experience challenges with weight management. Ideally patients identified as overweight or obese (BMI > 25 < 30 or BMI > 30, respectively) would have the following documented in their chart at each visit:

  • Diagnosis/listing of weight management, obese, overweight in the patient's problem list (use the "appropriate" code determined by your practice).
  • Indication that brief counseling around diet, exercise, weight management occurred during the encounter (use motivational interviewing approach).
  • Documentation of referral to external resource or that referral to resource was declined.
  • Plan for "next steps" related to healthy lifestyle maintenance/change.

Consider These Steps as You Refine the Documentation Process

  • Explore the current lay of the land:
  • What is the current format of your chart notes—do clinicians/staff tend to use text or templates?
  • What do chart notes look like when you see a patient with weight issues?
  • Discuss if there are opportunities for improving documentation of screening, problems, brief counseling, and referrals.
  • Determine a strategy for modifying existing templates or refining encounter text to capture the key elements.
  • Pilot test and refine your process!

Example Chart Notes for your Clinic's Use

Chart notes are often structured based on personal preference and/or the formatting capabilities of your Electronic Health Record. The two examples below (template and text format) provide learning models depicting how you might document brief counseling and referral for weight management. These models are provided as a "straw man" and clinics are strongly encouraged to discuss and refine according to local preferences and protocols.

Template Format—I discussed health consequences of weight including (diabetes, knee OA, hypertension, heart disease, etc.). We discussed (check all appropriate):

Weight   ___ Yes ___ No

Diet   ___ Yes ___ No 

Exercise   ___ Yes ___ No

We discussed referral to community resources for weight management: ___ Yes  ___ No

The patient expressed a desire for referral: ___ Yes ___ No

I referred the patient to:

___ Weight Watchers    ___ TOPS   ___ CHIP   ___ Other (specify): ____________________

Text Format

At-the-point example—Discussed weight, diet, exercise with patient in relation to health conditions.  Used motivational interviewing to illicit change talk and established initial goals with patient, including: walking daily to mailbox, reducing soda from 40 oz. daily to 20 oz., eating dinner at table 1 night per week.

After discussing patient preferences I referred [him/her] to [Weight Watchers, TOPS, etc] for additional follow-up. Patient plans to return in 2 months for follow-up appointment.

Another example—CC: Here for an annual check-up

Subjective: Susan is a 40 year old computer programmer who is here after a three-year hiatus from health care as she now has a job and health insurance. She is doing well overall. She is taking vitamins but no prescription medications. She realizes her weight is up from 3years ago but it has been a stressful time. She does not exercise but is thinking about getting back to this. Her exercise of choice is walking. Susan has started to watch her intake of sugar. She does not smoke and has one alcohol drink a month. She is single and has her own apartment. She is in a monogamous relationship and is thinking that she would like to have a family. Family history notes that an older sibling has weight issues and that Susan has a maternal aunt who developed breast cancer at age 51.

Objective: Ht. 70 inches; Wt. 294; BMI 42.3; BP 124/78; P-76

Gen app-comfortable, overweight

Assessment: Major health issue is obesity.

Plan: Discussed the importance of a healthy diet and exercise.

She feels she can get her weight down to 250 over the next 12 months.

She agrees to get a lipid and blood glucose check.

She is aware of the health hazards of obesity—including diabetes, knee osteoarthritis, and heart disease.

Susan will send a progress note in 6 months regarding her weight. If she is not making any progress, she agrees to connect with Weight Watchers.

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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Tool 7. Documenting the Conversation in Your Charts. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD.