Note may be listed in any order, subheadings optional
| DIETETICS STICKER/DATE/TIME | REASONS FOR REFERRAL/PRESENTING COMPLAINT/DIAGNOSIS |
| Assessment | |
| Food/Nutrition-related History Intake, administration (oral/enteral nutrition/parenteral nutrition), intravenous fluid, medication and herbal supplements, knowledge/beliefs/attitudes, seen by dietitian previously, behavior, meal-time behaviors, feeding difficulties, nutrition-related activities of daily living, nutrition-related quality of life, readiness to change, access to food, physical activity and function Anthropometric Measurements Height, weight, weight history, BMI, growth pattern indices/percentile, hand-grip strength, mid-upper arm circumference, Subjective Global Assessment Biochemical Data, Medical Tests and Procedures Examples include laboratory data, fluid balance tests, gastric residual volume, resting metabolic rate |
Nutrition-Focused Physical Findings
Nutrition Assessment, Monitoring and Evaluation Tools Tools used for health or disease status or risk assessment, reassessment, and monitoring and evaluation such as subjective global assessment tool ratings, nutrition assessment tool ratings, household food security tool ratings, food variety tool ratings |
| Diagnosis | |
| Problem—Use nutrition diagnoses terminology Etiology—“Root cause,” can use free text Signs and Symptoms—Quantifiable data, basis for monitoring and evaluation outcomes, free text. If no Nutrition Diagnosis: “No nutrition diagnosis exists” · Synthesize all assessment data 1. Inadequate oral intake as related to cancer treatment and associated nausea, vomiting and inability to prepare meals as evidenced by BMI: 15 kg/m2 and 20% loss of body weight in 3/12 and consuming only 2 small meals/day
2. Inadequate protein–energy intake as related to poor appetite and elevated requirements as evidenced by patient consuming ~50% of requirements 1 000 kcal (4 000 kJ) and 40 g protein/day |
|
| Intervention | |
| Nutrition Prescription/Goal Nutrition Intervention Food and/or Nutrient Delivery Meal and snacks Enteral and parenteral nutrition Oral or vitamin/mineral supplement (type frequency) Feeding assistance (opening packages) and environment Nutrition-related medication management, such as. anti-emetic Nutrition Education What was provided? What resources given? Nutrition Counseling Theoretical basis, such as cognitive behavioral therapy Strategies, such as counseling, goal setting, rewards Coordination of Nutrition Care Coordination of care with others, such as food charts, weight Discharge and transfer of nutrition care |
Prescription—Patient’s individualized recommended dietary intake of energy/selected food or nutrients based on reference standards or dietary guidelines Example—Increase intake by 1 000 kcal (4 000 kJ) and 40 g protein/day to provide 2 000 kcal (8 000 kJ) 90 g protein (1.5 g/kg) Goal—High-energy, high-protein diet for weight maintenance during admission Plan Commence oral nutrition supplements providing 1 000 kcal (4 000 kJ) and 45 g protein Educate patient and family on importance of nutrition weight maintenance and optimal treatment outcomes. Education resources provided |
| Monitoring and Evaluation | |
| Follow-up Time What will you assess at review? Food/Nutrition-related History
Anthropometric measurements Biochemical data, medical tests, procedures Nutrition-focused physical findings Nutrition assessment, monitoring, and evaluation tools
|
Includes Information to be assessed at next review to determine if goal/prescription and interventions have been implemented and are effective Signs and symptoms from PES Statements Data for monitoring progress (patient understanding or compliance with intervention), measurement and evaluation of outcomes (data to compare to nutrition goals). Prescription to determine further action |
References
From eNCPT, electronic Nutrition Terminology Reference Manual, 2016 Edition. Copyright © 2016 by Academy of Nutrition and Dietetics, Adapted with permission of Academy of Nutrition and Dietetics.
Adapted by Qld Government. January 2012. H. Parker for JHC Dietetics Dept. Updated July 2015 WA. NCPT Champions Group. Edited by Stewart, Vivanti, Myers 2015