What components should be included in a SOAP note template for weight loss management?

SOAP Note Template for Weight Loss Management

A comprehensive SOAP note for weight loss management should systematically document anthropometric measurements, cardiovascular risk factors, dietary intake patterns, physical activity levels, behavioral readiness, and create an actionable plan with specific caloric targets and follow-up intervals.

Subjective Section

Chief Concern and Motivation

• Document patient's primary reason for seeking weight management and their personal health goals that matter most to them 1
• Assess readiness to change by determining motivation level, current life stressors that may interfere with weight loss efforts, and ability to commit 15-30 minutes daily for the next 6 months 1
• Screen for psychiatric conditions including severe depression, substance abuse, or binge eating disorder that could derail weight loss efforts 1

Weight History

• Record current weight, usual adult weight, highest adult weight, and lowest adult weight 1
• Document previous weight loss attempts, methods used, amount lost, duration maintained, and reasons for regain 1
• Assess weight trajectory over the past 6-12 months 2

Dietary Assessment

• Obtain specific estimates of total daily caloric intake including saturated fat, trans fat, cholesterol, and sodium content 1
• Document eating patterns: number of meals and snacks per day, frequency of dining out, consumption of fruits/vegetables/whole grains/fish, and alcohol intake 1
• Assess consumption of refined carbohydrates, sugar-sweetened beverages, processed meats, and ultra-processed foods 2

Physical Activity Assessment

• Record current physical activity levels including type, frequency, duration, and intensity of exercise 1
• Document sedentary behaviors including screen time and occupational sitting 2

Medication Review

• List all current medications with attention to weight-promoting effects (antipsychotics, antidepressants, corticosteroids, insulin, sulfonylureas) 2
• Document use of nonprescription drugs that may affect weight or blood pressure 1

Social Determinants of Health

• Screen for housing stability, food insecurity, education level, and neighborhood built environment 1

Objective Section

Anthropometric Measurements

• Measure and record weight (kg), height (cm), and calculate BMI (kg/m²) 1
• Measure waist circumference at the level of the iliac crest: document if ≥40 inches (102 cm) in men or ≥35 inches (88 cm) in women 1
• Measure neck circumference to screen for obstructive sleep apnea 1

Vital Signs

• Measure seated resting blood pressure on both arms 1
• Measure lying, seated, and standing blood pressure to rule out orthostatic hypotension 1
• Record resting heart rate 1

Laboratory Values

• Fasting lipid panel: total cholesterol, LDL-C, HDL-C, triglycerides, non-HDL-C 1
• Fasting plasma glucose and hemoglobin A1c to screen for diabetes (≥126 mg/dL or ≥6.5%) or prediabetes (100-125 mg/dL or 5.7%-6.4%) 1
• Liver function tests and consider Fibrosis-4 Index calculation for nonalcoholic fatty liver disease screening 1
• TSH if clinically indicated 1

Screening for Comorbidities

• Document presence or absence of: type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea (using STOP-BANG score if indicated), osteoarthritis, gastroesophageal reflux disease, metabolic syndrome 1
• Calculate cardiovascular risk using appropriate risk calculator 1

Assessment Section

Weight Classification

• Classify weight status: overweight (BMI 25.0-29.9 kg/m²), class I obesity (BMI 30.0-34.9 kg/m²), class II obesity (BMI 35.0-39.9 kg/m²), or class III obesity (BMI ≥40 kg/m²) 1
• Note ethnicity-specific thresholds if applicable (South/Southeast Asian: overweight ≥23 kg/m²) 3

Risk Stratification

• Identify obesity-related comorbidities present and their current control status 1
• Assess cardiovascular risk factors: hypertension, dyslipidemia, hyperglycemia, family history 1
• Document metabolic syndrome if ≥3 criteria present: waist circumference ≥88 cm (women) or ≥102 cm (men), triglycerides ≥150 mg/dL, fasting glucose ≥100 mg/dL, blood pressure ≥130/85 mmHg, HDL-C <40 mg/dL (men) or <50 mg/dL (women) 1

Readiness Assessment

• Categorize patient readiness: ready for weight loss intervention vs. not ready (focus on weight stabilization and barrier exploration) 1

Problem List

• List specific problems requiring intervention: obesity with BMI [specific value], inadequate physical activity, excessive caloric intake, specific dietary deficiencies, uncontrolled comorbidities 1

Plan Section

Weight Loss Goals

• Establish initial weight loss target of 5-10% of body weight over 6 months (rate of 1-2 lb/week) 1
• For overweight patients (BMI 25-29.9) with ≥2 cardiovascular risk factors: aim for 500 kcal/day deficit resulting in ~1 lb/week loss 1
• For class I obesity (BMI 30-34.9): aim for 500 kcal/day deficit 1
• For class II-III obesity (BMI ≥35): aim for 500-1000 kcal/day deficit resulting in 1-2 lb/week loss 1

Dietary Prescription

• Prescribe specific caloric target: 1200-1500 kcal/day for women, 1500-1800 kcal/day for men (adjusted for body weight) 1
• Alternative approach: prescribe 500-750 kcal/day energy deficit from current intake 1
• Dietary composition targets: saturated fat <7% of total energy, trans fat <1%, cholesterol <300 mg/day, sodium ≤1500 mg/day 2
• Recommend specific dietary pattern: Therapeutic Lifestyle Change diet or evidence-based diet that restricts high-carbohydrate, low-fiber, or high-fat foods 1
• Consider portion-controlled servings or meal replacements to enhance compliance 1

Physical Activity Prescription

• Prescribe 60-90 minutes of moderate-intensity aerobic activity daily for meaningful weight reduction 2
• Include resistance training 2-3 times per week to preserve lean mass 1, 2
• For weight maintenance after loss: prescribe 200-300 minutes weekly minimum 2, 4
• Recommend reduction of sedentary behaviors and screen time 2

Behavioral Interventions

• Refer to or prescribe comprehensive lifestyle program with ≥14 sessions over 6 months (high-intensity intervention) 1
• Implement daily self-monitoring of food intake, physical activity, and body weight 2
• Prescribe weekly weigh-ins 2
• Incorporate behavior change models: goal setting, stimulus control, stress management, cognitive therapy 1
• Provide education on portion control using measured servings 2

Pharmacotherapy Consideration

• If BMI ≥30 or BMI ≥27 with weight-related comorbidities AND lifestyle modifications fail after 3-6 months: initiate anti-obesity medication such as GLP-1 receptor agonists (semaglutide, liraglutide), phentermine-topiramate ER, or naltrexone-bupropion 1, 2
• If weight gain exceeds 2 kg in one month or ≥7% from baseline: consider adjunctive metformin or topiramate 2
• Review and adjust weight-promoting medications in consultation with prescribing provider 2

Comorbidity Management

• Blood pressure management: If 120-139/80-89 mmHg, intensify lifestyle modifications; if ≥140/90 mmHg, add or adjust antihypertensive therapy 1
• Lipid management: Adjust statin therapy to achieve LDL-C goals per current guidelines 1
• Diabetes management: Adjust glucose-lowering medications, preferentially using agents that promote weight loss (GLP-1 agonists, SGLT2 inhibitors) 1

Referrals

• Refer to registered dietitian for individualized nutrition counseling 1
• Refer to obesity medicine specialist if weight loss goals not achieved with primary care interventions 1
• Consider referral for bariatric surgery evaluation if BMI ≥35 with comorbidities or BMI ≥40 1
• Refer for sleep study if STOP-BANG score suggests high risk for obstructive sleep apnea 1

Follow-Up Schedule

• Schedule monthly visits for first 3 months, then every 3 months thereafter 2
• Expected outcomes at 6 months: 8 kg weight loss with comprehensive lifestyle intervention 2
• Expected outcomes at 12 months: 8 kg maintained with continued biweekly-monthly contact 2
• Reassess and intensify therapy if progressive weight loss not achieved; consider adding pharmacotherapy or referral to specialized programs 1

Patient Education

• Counsel that 3-5% weight loss produces clinically meaningful reductions in triglycerides, blood glucose, and diabetes risk 1
• Educate that greater weight loss (5-10%) improves blood pressure, LDL-C, HDL-C, and reduces medication needs 1
• Discuss obesity as chronic disease requiring long-term management with expectation of gradual regain (1-2 kg/year) without ongoing intervention 1, 4
• Provide written materials on dietary goals, physical activity targets, and self-monitoring techniques 1

Documentation of Barriers

• Document specific barriers identified: time constraints, financial limitations, lack of social support, physical limitations, psychological factors 1
• Record plan to address each barrier 1