S3470C Assessment Brief

Case Study

A client was referred to you for a nutrition assessment and diagnosis.

Case Study: Mr Lim Ah Poh

Refered Client:

Name: MrLim Ah Poh

Age: 54years old

Gender: Male

Ethnicity: Chinese

Height: 168cm

Weight: 90kg

Occupation: Administration Executive

Living siutation: Lives with wife and 1 daughter in a 3 room HDB flat

Highest education qualification: Secondary School

Diagnosed condition:

Type 2 Diabetes Mellitues – Diagnosed2 years ago, on metformin
Hypertension–Just diagnosed, have not started on medication

Recent Blood Test Results:

HbA1c: 8.5%
Fasting Glucose: 14.9 mmol/L
Total Cholesterol: 4.8 mmol/L
LDL: 2.9 mmol/L
HDL: 1.1 mmol/L
Triglycerides: 2.2 mmol/L
Blood Pressure: 149/95 mmHg

Social & Lifestyle Factors:

Financial struggles – Relies on savings, preparing daughter’s university education. Wife is housewife at home.
Sedentary lifestyle –Apart from commuting to work and back home, Mr Lim don’t do any other exercise.
Stress eating –Like to consume sweetened beverages
Social interaction –Interacts mainly with colleagues and spend time with wife and daughter at home.

24 hours Dietary History:

Meals

Food items

Remarks

Breakfast8am

1 cup Kopi (Ga Dai – add extra sugar)

2 slices Toast with peanut butter

Purchased from office canteen

Snack

10am

1 bottle Coke (500ml)

4 pieces Plain Cracker (Flavour: Salted)

Eat at work

Lunch

1pm

10 pieces Fried Chicken Nuggets (180g)

5 packets Chilli Sauce

1 bowl White Rice

1 Fried Egg with Dark Soya Sauce

1 bottle Fanta Grape drink (500ml)

Purchased from the office canteen

Snack

3pm

1 can Red Bull (330ml)

4 pieces Plain Cracker (Flavour: Salt and Pepper)

Eat at work

Dinner

7pm

¼ plate Braised Vegetable

1 palm size Fried Fish

2 Fried Eggs

1 bowl of Mixed Brown and White Rice

1 small Pear

1 can Sprite (330ml)

Wife’s cooking

Supper

11pm

1 bottle Fanta Orange drink (500ml)

8 pieces Plain Cracker (Flavour: Salt and Pepper)

Felt hungry before sleeping

Based on the information above, you are required to use the Nutrition Care Process (S.O.A.P) and the Nutrition Assessment Form to discuss the process of disease-nutrition care that your client should receive to manage his medical conditions.

Write a (S.O.A.P.) entry for the Mr Lim Ah Poh.

Subjective (10%)
Objective (10%)
Assessment (10%)
Plan (10%)
*Monitoring (10%)*

S3470C Assessment Marking Criteria

Descriptors
Grading Criteria	Excellent	Good	Acceptable	Weak
Subjective entry: Contains client’s subjective communications, feeling and complaints, nutritionally significant food habits and diet history.	Entry and recording of client’s subjective input with appropriate evaluation of client’s prescribed needs were detailed and accurate.	Entry and recording of client’s subjective input with appropriate evaluation of client’s prescribed needs were detailed but contained some errors.	Entry and recording of client’s subjective input with appropriate evaluation of client’s prescribed needs were brief and contained some errors.	Entry and recording of client’s subjective input with appropriate evaluation of client’s prescribed needs were brief and contained many errors.
Objective entry: Significant data from lab report, anthropometric data, medical diagnosis, diet prescription and medications.	Entry and recording of client’s objective input with appropriate evaluation of client’s prescribed needs were detailed and accurate.	Entry and recording of client’s objective input with appropriate evaluation of client’s prescribed needs were detailed but contained some errors.	Entry and recording of client’s objective input with appropriate evaluation of client’s prescribed needs were brief and contained some errors.	Entry and recording of client’s objective input with appropriate evaluation of client’s prescribed needs were brief and contained many errors.
Assessment: Analysis and interpretation of S and O, detailed diet recommendations, level of motivation to change/stage of change, possible problems or barriers, appropriateness of current diet.	Interpretation and analysis of subjective and objective entries to derive at a diet recommendation was detailed and took into consideration all of the following: levels of motivation to change, stage of change, possible problems or barriers and appropriateness of current diet.	Interpretation and analysis of subjective and objective entries to derive at a diet recommendation was detailed and took into consideration most of the following: levels of motivation to change, stage of change, possible problems or barriers and appropriateness of current diet.	Interpretation and analysis of subjective and objective entries to derive at a diet recommendation was detailed and took into consideration some of the following: levels of motivation to change, stage of change, possible problems or barriers and appropriateness of current diet.	Interpretation and analysis of subjective and objective entries to derive at a diet recommendation was detailed and took into consideration a few of the following: levels of motivation to change, stage of change, possible problems or barriers and appropriateness of current diet.
Monitoring: Follow-up and evaluation of prescribed nutrition strategy	Monitoring was documented with a detailed follow-up and accurate evaluation of prescribed nutrition strategy.	Monitoring was documented with a detailed follow-up, but evaluation of prescribed nutrition strategy contained errors.	Monitoring was documented with a brief follow-up and evaluation of prescribed nutrition strategy contained errors.	Monitoring was documented with a brief follow-up and evaluation of prescribed nutrition strategy contained many errors.
Plan: Plans coincide with client’s goals, is/are measurable.	Plans were developed with all of the SMART principles fulfilled and resonated with the client’s goals including forward planning.	Plans were developed with most of the SMART principles fulfilled and resonated with the client’s goals.	Plans were developed with some of the SMART principles fulfilled and while in alignment with the client’s goals, may not have taken into consideration the client’s preferences.	Plans were developed with none of the SMART principles fulfilled and not in alignment with the client’s goals.

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University	Republic Polytechnic (RP)
Subject	S3470C Nutrition Care Process

S3470C Nutrition Care Process Assessment Brief 2026 | Republic Polytechnic, Singapore

S3470C Assessment Brief

Case Study

S3470C Assessment Marking Criteria

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