Edit Clinical Notes AOHC - Adult Nutrition
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Vital Signs:
c Premature d e f g graph sheet
HT:
graph sheet
WT:
Add BP CM KG
percentile:
Mother's Stature
percentile:
Father's Stature
HT/WT:
percentile:
BMI:
percentile:
Add PEFR CM CM
Status:
BSA: graph sheet
Systolic
graph sheet
CM
WC:
BP:
Diastolic
Limb
HR:
BPM:
Rhythm:
graph sheet
RR:
BPM:
Desc:
graph sheet
T:
graph sheet
SpO2:
째C
5
2
2013
^ DD/MM/YYYY
Desc:
Location:
L/min
PEFR:
Date
Adult
/
graph sheet
graph sheet
Cuff Size
n pre-bronchodilator m i j k l m n post-bronchodilator j k l
graph mmol/L BS: sheet Current Nutritional Issues:
5
2
2013
^
DD/MM/YYYY
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Referral Reason:
5
6 Aspiration/Dysphagia: g c d e f Aspiration/Dysphagia Comments:
Bloating:
Heart Healthy: g c d e f Heart Healthy Comments:
5
5
6
6 Low Iron: g c d e f
c d e f g
Bloating Comments:
Changes in Appetite:
Low Iron Comments:
c d e f g
5
5
6
6 Mouth
c d e f g
Changes in Appetite:
Mouth Sores: Mouth Sores Comments:
c d e f g Changes in Appetite Comments: 5
c d e f g
5
6 Chronic Constipation: g c d e f Chronic Constipation Comments:
Gas: f g c d e Gas Comments:
5
5
6
6
GU: g c d e f GU Comments:
Nausea: g c d e f Nausea Comments:
5
5
6
6
Constitutional SN/A: g c d e f Constitutional SN/A Comments:
Pain: g c d e f Pain Comments:
5
5
6
6
Dentition/Difficulty Chewing: g c d e f Dentition/Difficulty Chewing Comments:
Prenatal Nutrition: g c d e f Prenatal Nutrition Comments:
5
5
6
6
Diarrhea: g c d e f Diarrhea Comments:
Reflux/Heartburn:
c d e f g
Reflux/Heartburn Comments:
5
5
6
6
Disease Management: f g c d e Disease Management Comments:
Disease Prevention: f g c d e Disease Prevention Comments:
6
Sport Nutrition: g c d e f Sport Nutrition Comments:
5
5
6
6 TPN/Tube Feeding: g c d e f TPN/Tube
Disease Prevention Comments:
TPN/Tube
5 Feeding
Comments:
5
6 Edema: g c d e f
6
Vomiting: g c d e f Vomiting Comments:
Edema Comments:
5
5
6
6
Emotional Eating: g c d e f Emotional Eating Comments:
Weight Gain: g c d e f Weight Gain Comments:
5
5
6
6
Fatigue/Weakness: f g c d e Fatigue/Weakness Comments:
Weight Loss: g c d e f Weight Loss Comments:
5
5
6
6
Other Nutritional Issues:
5
6
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Nutritional Risk Factors:
Sepsis: g c d e f Sepsis Comments:
Age: g c d e f Age Comments:
5
5
6
6
Cognitive Deficit/Impairment: g c d e f Cognitive Deficit/Impairment Comments:
Fever: g c d e f Fever Comments:
Cardiac Disease: g c d e f Cardiac Disease Comments:
5
5
6
6 Respiratory Disease: g c d e f Respiratory
Fever Comments:
5
Respiratory Disease Comments:
5 6 Albumin<35: g c d e f Albumin<35 Comments:
Surgery/Procedures: g c d e f Surgery/Procedures Comments:
5
5
6
6
Compromised Nutritional Status: g c d e f Compromised Nutritional Status Comments:
CVA: g c d e f CVA Comments:
5
5
6
6
Severe Infection: g c d e f Severe Infection Comments:
Skin Breakdown/Wound: g c d e f Skin Breakdown/Wound Comments:
5
5
6
6
Cancer: g c d e f Cancer Comments:
GI Disorders/Diseases: g c d e f GI Disorders/Diseases Comments:
5
5
6
6
HIV: g c d e f HIV Comments:
Diabetes: g c d e f Diabetes Comments:
5
5
6
6
Hypercholesterolemia: g c d e f Hypercholesterolemia Comments:
Hypertrigylceridemia: f g c d e Hypertrigylceridemia Comments:
6
Dehydration: g c d e f Dehydration Comments:
5
5
6
6 Renal Failure: g c d e f Renal
5 Failure Comments:
5
5 Comments: 5 6 Hypertension: g c d e f Hypertension Comments:
Disordered Eating Patterns: g c d e f Disordered Eating Patterns Comments:
5
5
6
6
Vitamin/Mineral Deficiency: g c d e f Vitamin/Mineral Deficiency Comments:
Eating Disorder: f g c d e Eating Disorder Comments:
5
5
6
6
Iron deficiency (without anemia): g c d e f Iron deficiency (without anemia) Comments:
Bulimia Nervosa: g c d e f Bulimia Nervosa Comments:
5
5
6
6
Iron deficinecy (anemia): g c d e f Iron deficinecy (anemia) Comments:
GERD: g c d e f GERD Comments:
Anorexia Nervosa: g c d e f Anorexia Nervosa Comments:
5
5
6
6 Binge Eating Disorder: g c d e f Binge Eating Disorder Comments:
5
5
6
6
Allergies: g c d e f Allergies Comments:
Intolerances: g c d e f Intolerances Comments:
6
Obesity: g c d e f Obesity Comments:
5
5
6
6
Other
5 Comments:
5
6
6
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Dietitian Database:
Goal Weight:
KG/M²: Normal Under WT Over WT Obese
Do you mind if we talk about your weight? Yes No
Usual Body Weight:
Realistic? Yes No
Daily Energy Requirement:
5
5
6
6
Adjusted Body Weight:
Daily Protein Requirement:
5
5
6
6
Weight History:
Daily Fluid Requirement:
5
5
6
6
Mobility/ADLs:
HN/A Weight Management Methods:
5
5
6
6 Current Weight Management Methods:
Bioelectrical Impedance Analysis: Yes No
5
6
Simple Table Harris Benedict Equation (HBE x Activity Factor = Total Energy Expenditure) Weight (kg) Male Female
Height (cm)
Age (yrs)
HBE
65 + (13.7 x
) + (5.00 x
) - ( 6.76 x
=
X
65.5 + (9.56 x
) + (1.85 x
) - ( 4.68 x
=
X
Ideal Body Weight Range: % Weight Change:
Fat Mass
Mass Fat Free Mass (pounds): (pounds): Total Body Water (pounds):
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Physical Activity: Physical Activity:
Activity 1 Type:
5
Activity 1 Intensity Level: Low Moderate High
6 Activity 1 Duration:
Activity 1 Frequency:
5
5
6
6
Activity 2 Type:
5 Activity 2 Intensity Level: Low Moderate High
Activity 2 Duration:
6
Activity 2 Frequency:
5
5
6
6
Activity 3 Type:
5 Activity 3 Intensity Level: Low Moderate High
Activity 3 Duration:
6
Activity 3 Frequency:
5
5
6
6
Activity 4 Type:
5
Activity 4 Intensity Level: Low Moderate High
Activity 4 Duration:
6 Activity 4 Frequency:
5
5
6
6
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Evaluation of Previous Goals: Evaluation of Previous Goals N/A (first visit): g c d e f Success of Implementing Goals:
Follow Up Plan:
Challenges of Implementing Goals:
5
5
6
6
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Follow Up Plan / To be discussed next time:
5
6