INTENSIVE BEHAVIOR THERAPY for OBESITY PROGRAM RECORD and PROGRESS NOTE

INTENSIVE BEHAVIOR THERAPY for OBESITY PROGRAM RECORD and PROGRESS NOTE

ABC HOSPITAL
INTENSIVE BEHAVIOR THERAPY FOR OBESITY PROGRAM RECORD and PROGRESS NOTE
Patient:______Provider:______ Initial 12 months  Subsequent 12 months
RECORD VISIT # 1
/ ACTUAL / PROGRESS NOTE: Visit #______Date:______
Behavior  tools used^:
Wt:  or  by ______# Wt Goal:
Ht: BMI: Waist circum: BP:
Waist-hip ratio:
Other Outcomes:
Rx Meds:
 None  No change  Request 
Behavior Goals Collaboratively Created related to:
 Healthy eating  Being active  Taking meds
 Pt monitoring  Support  Problem-solving
  barriers to  ______
 ______ Handouts provided
 PHYSICIAN ACTION REQUESTED
 SEE Addendum Note Attached
nOTES:
 Assessment  Wt loss targets + benefits  Excess wt harms / Date:
Initials:
Hrs: 0.25 0.5 1 2
 Individual  Group
Also present:
 Other health outcomes  Behavior goals  Medicare review
 Pt monitoring logs  Other behavior  strategies
 Reviewed topic of:
 Other:
RECORD VISIT # __
/ Date:
Initials:
Hrs: 0.25 0.5 1 2
 Individual  Group
Also present:
 Corrected knowledge deficits  Behavior change strategies
 Behavior goals  Goal achievement   barriers to 
 Review of monitoring logs/outcomes  Support for behavior 
 Reviewed topic of:
 Other:

RECORD VISIT # __

/ Date:
Initials:
Hrs: 0.25 0.5 1 2
 Individual  Group
Also present:
 Corrected knowledge deficits  Behavior change strategies
 Behavior goals  Goal achievement   barriers to 
 Review of monitoring logs/outcomes  Support for behavior 
 Reviewed topic of:
 Other:

RECORD VISIT # __

/ Date:
Initials:
Hrs: 0.25 0.5 1 2
 Individual  Group
Also present:
 Corrected knowledge deficits  Behavior change strategies
 Behavior goals  Goal achievement   barriers to 
 Review of monitoring logs/outcomes  Support for behavior 
 Reviewed topic of:
 Other:
RECORD VISIT # __ / Date:
Initials:
Hrs: 0.25 0.5 1 2
 Individual  Group
Also present:
 Corrected knowledge deficits  Behavior change strategies
 Behavior goals  Goal achievement   barriers to 
 Review of monitoring logs/outcomes  Support for behavior 
 Reviewed topic of:
 Other:
RECORD VISIT #__ / Date:
Initials:
Hrs: 0.25 0.5 1 2
 Individual  Group
Also present:
 Corrected knowledge deficits  Behavior change strategies
 Behavior goals  Goal achievement   barriers to 
 Review of monitoring logs/outcomes  Support for behavior 
 Reviewed topic of:
 Other:
RECORD VISIT #__ / Date:
Initials:
Hrs: 0.25 0.5 1 2
 Individual  Group
Also present:
 Corrected knowledge deficits  Behavior change strategies
 Behavior goals  Goal achievement   barriers to 
 Review of monitoring logs/outcomes  Support for behavior 
 Reviewed topic of:
 Other:
RECORD VISIT #__ / Date:
Initials:
Hrs: 0.25 0.5 1 2
 Individual  Group
Also present:
 Corrected knowledge deficits  Behavior change strategies
 Behavior goals  Goal achievement   barriers to 
 Review of monitoring logs/outcomes  Support for behavior 
 Reviewed topic of:
 Other:
^ K = Knowledge S = Skill G = Goal Setting M =Monitoring by Pt C = Confidence O = Obstacles P = Problem Solving H =Handouts DS = Discussion D = Demo V=Video
Other: Educator Signature/Initials:
ABC HOSPITAL
INTENSIVE BEHAVIOR THERAPY FOR OBESITY PROGRAM RECORD and PROGRESS NOTE
Patient:______Provider:______Date:______

Addendum Note

______

______

______

______

______

______

______

Educator Signature/Initials: Educator Signature/Initials:

MARY ANN HODOROWICZ CONSULTING, LLC

Nutrition, Diabetes Care & Education, Health Promotion and Insurance Reimbursement for

Professionals for the Healthcare and Food Industry

12921 Sycamore  Palos Heights, IL 60463  Ph: 708.359.3864  Fax: 866.869.6279

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