Blank Clinical Forms

Nutrition Progress Note (quarterly)

January 11, 2017   /
Author: 
Lori Willis, RD
Nutrition411 Staff

Patient name:________________________________ Physician:_____________________

Room:_______________ Registered dietitian: _______________________________________

Food allergies:___________________________ Height:________

IBW range: ________lb UBW: ________lb

Weight/Diet/Intake
Date:        
Current weight

Wt____

Date ____

Wt____ 

Date ____

Wt____ 

Date ____

Wt____ 

Date ____

Significant weight change

No ___

Yes; % wt change at

1 mo____

3 mo____

6 mo____

No ___

Yes; % wt change at

1 mo____

3 mo____

6 mo____

No ___

Yes; % wt change at

1 mo____

3 mo____

6 mo____

No ___

Yes; % wt change at

1 mo____

3 mo____

6 mo____

Current diet/fluids

Diet:__________

Fluids:_________

Hydration score:____

Diet:__________

Fluids:_________

Hydration score:____

Diet:__________

Fluids:_________

Hydration score:____

Diet:__________

Fluids:_________

Hydration score:____

Usual % food intake

75%-100% __

25%-50%   __

50%-75%   __

75%-100% __

75%-100% __

25%-50%   __

50%-75%   __

75%-100% __

75%-100% __

25%-50%   __

50%-75%   __

75%-100% __

75%-100% __

25%-50%   __

50%-75%   __

75%-100% __

Snack/supplement

No___
Yes; type:________

Accepts: Y    N

No___
Yes; type:________

Accepts: Y    N

No___
Yes; type:________

Accepts: Y    N

No___
Yes; type:________

Accepts: Y    N

Functional Status

Dental issues impacting ability to eat/drink

No___

Yes, describe in summary___

No___

Yes, describe in summary___

No___

Yes, describe in summary___

No___

Yes, describe in summary___

Able to eat/drink by self

Yes___

No, describe in summary___

Yes___

No, describe in summary___

Yes___

No, describe in summary___

Yes___

No, describe in summary___

Adaptive devices for eating/drinking

No___

Yes, describe in summary___

No___

Yes, describe in summary___

No___

Yes, describe in summary___

No___

Yes, describe in summary___

Clinical Status

GI issues

No___

Yes, describe in summary___

No___

Yes, describe in summary___

No___

Yes, describe in summary___

No___

Yes, describe in summary___

Medications related to dietary needs        
Skin impairment

No____ Yes ____

Braden score: ____

No____ Yes ____

Braden score: ____

No____ Yes ____

Braden score: ____

No____ Yes ____

Braden score: ____

Labs reviewed

No new labs since last review__

Changes, describe in summary__

No new labs since last review__

Changes, describe in summary__

No new labs since last review__

Changes, describe in summary__

No new labs since last review__

Changes, describe in summary__

Dining Experience

Usual dining experience

Dining room___

In room, describe:

 

Dining room___

In room, describe:

 

Dining room___

In room, describe:

 

Dining room___

In room, describe:

 
Food preference changes

No___

Yes, describe in summary___

No___

Yes, describe in summary___

No___

Yes, describe in summary___

No___

Yes, describe in summary___

Care plan Changes made/updated__  Changes made/updated__  Changes made/updated__  Changes made/updated__ 

GI=gastrointestinal, IBW=ideal body weight, mo=month, N=no, UBW=usually body weight, Wt=weight, Y=yes

 

Signature/Title_____________________________________________

Date________________
 

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Summary:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

References: and recommended readings

Nutrition critical element pathway. Centers for Medicare and Medicaid Services website. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/CMS-20075-Nutrition.pdf. Accessed December 2, 2015.