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