Max is an 11-year-old boy who was admitted to the hospital after he passed out while playing with friends. Tests confirm a diagnosis of type 1 diabetes mellitus. Max remains in the hospital for several days until his blood glucose and ketone levels are under control. During this time, he and his family learn about diabetes, the diet Max needs to follow, the use of insulin, the monitoring of blood glucose levels, and the required coordination of food intake, insulin, and physical activity. The details of diabetes mellitus are reserved for Chapter 26, but for now you can consider the steps that are necessary for implementing Max’s nutrition care.
After a first visit with Max and his family, what information should the dietitian add to Max's medical record? Is enough information given above for completing a SOAP note? If not, what elements are missing?