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NUTRITIONAL ASSESSMENT AND RISK LEVEL FORM 2025

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The document is a Nutritional Assessment and Risk Level Form used to evaluate a patient's nutritional status upon admission. It includes sections for patient information, criteria for assessing weight loss, food intake, gastrointestinal symptoms, functional capacity, and physical examination. Based on the collected data, patients are assigned a nutrition risk level (low, moderate, or high) which determines the need for follow-up by a Clinical Nutrition Physician or Dietitian.

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Click ‘Get Form’ to open the NUTRITIONAL ASSESSMENT AND RISK LEVEL FORM in the editor.
Begin by entering the 'Date Admitted', 'Room / Bed No.', and 'File No.' at the top of the form. This information is crucial for patient identification.
Fill in the patient's personal details, including their name, age, height, and weight. Accurate data here is essential for assessing nutritional needs.
In the 'Criteria' section, evaluate weight loss and BMI. Select appropriate options based on clinical observations to determine risk levels.
Assess food intake over the last 1-2 months and any gastrointestinal symptoms. Document findings clearly to provide a comprehensive overview.
Complete the 'Physical Examination' section by noting any edema or ascites and calculating scores for SGA Grade, Albumin levels, and TLC.
Finally, review the total score to determine the NUTRITION RISK LEVEL and indicate if a referral to a Clinical Nutrition Dietitian is necessary.

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What are the 5 diet assessment methods?

Traditional methods of dietary assessment include food records, food frequency questionnaires, 24-hour recalls, and screening tools; digital and mobile methods that leverage technology are available for these traditional methods.

What are the 5 domains of nutrition assessment?

The five domains of nutrition assessment outlined in the NCP include 1) food or nutrition-related history, 2) biochemical data, medical tests, and procedures, 3) anthropometric measurements, 4) nutrition-focused physical findings, and 5) client history.

How to write a nutrition assessment?

Lets go through each part of the above assessment and look at whats included. Who and what (M/F, age, admitting diagnosis, PMH) Pertinent medications, skin integrity, notable lab values. Weight status, current diet order, ONS, or additional supplements. Recommendations and interventions. Goals, follow-up plan.

What are the 5 components of the nutrition care process?

Stages of the Nutrition Care Process Nutrition Assessment. Nutrition Diagnosis. Nutrition Intervention. Nutrition Monitoring and Evaluation.

What is a nutritional risk assessment?

Such an assessment includes subjective and objective parameters such as medical history, current and past dietary intake (including energy and protein balance), physical examination and anthropometric measurements, functional and mental assessment, quality of life, medications, and laboratory values.