This is a modified sample of what we use at our acute care facility. Could easily be modified for long-term care. I saved it as a word document so you can download and adjust as needed. Useful for new dietitians entering the clinical setting, returning dietitians to the clinical setting, and dietetic interns. Includes assessment of patient’s weight, diet history, chewing/swallowing problems, etc. Nutrition Focused Physical Assessment Data. Areas to record significant lab and medication information. Estimation of energy, protein, and fluid needs. PES statement. SMART goals with examples.
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