Form - Dietary requirements assessment (all providers)19.82 KB

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Form – Dietary requirements assessment
Suitable for all providers
Nutritional assessment or screening is the process of identifying people who may be malnourished or dehydrated or at risk of becoming so. Providers can use
the following sample assessment framework, adapting it for their own use and needs as required.
Part 1 – Current Diet
This part of the assessment records general information about the service user, their eating patterns, likes, dislikes and other dietary information.
Name:
DOB:
Do you usually eat breakfast? YES/NO
Details:
Do you usually eat lunch? YES/NO
Details:
Do you usually eat an evening meal? YES/NO
Details:
Have you gained weight in the last year? YES/NO
Details:
Have you lost weight in the last year? YES/NO
Details:
Do you follow a special diet (cultural/medical/etc.)? YES/NO
Details:
Do you have any known food allergies? YES/NO
Details:
Do you have any food preferences? YES/NO
Details:
Do you take/need any food supplements? YES/NO
Details:
Are you taking any medication? YES/NO
Details:
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Height:
Weight:
Do you have any long-term medical conditions? YES/NO
Details:
Do you have any history of digestive problems? YES/NO
Details:
Do you need any help with eating (i.e. feeding)? YES/NO
Details:
Do you need any help with drinking? YES/NO
Details:
Do you have any difficulty swallowing food? YES/NO
Details:
Do you have any difficulty swallowing liquids? YES/NO
Details:
Do you have any trouble with dentures/teeth? YES/NO
Details:
Part 2 – Dietary Risk
This part of the assessment allows the home to identify a nutritional risk category for each service user, i.e. high, medium or low.
Ability to eat
-
Unable to take food orally, unable to swallow, severe vomiting and/or diarrhoea (more than 2–3 times a
day)
Difficulty in swallowing. Moderate vomiting and/or diarrhoea (more than once a day) – needs help feeding
Problems handling food, e.g. needs adapted cutlery – assistance and encouragement required
No difficulties eating
Score:
3
Score:
Score:
Score:
2
1
0
Score:
Score:
Score:
Score:
3
2
1
0
Current Appetite
-
Appetite virtually nil or unable to eat
Poor appetite – leaving half of meals provided, poor food and fluid intake
Average appetite — eats more than half of meals, 2/3 a day
Good appetite — manages most of 3 meals a day
Low body weight
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-
Female aged over 75 weighing under 45Kg. (7st) or Male aged over 75 weighing under 53Kg. (8st 5lb)
Female aged 55–74 weighing under 50Kg. (7st 10lb) or Male aged 55–74 weighing under 57Kg. (9st)
Body weight not low
Score:
Score:
Score:
2
1
0
Score:
Score:
Score:
Score:
3
2
1
0
Score:
Score:
Score:
Score:
3
2
1
0
Unintentional weight loss in last 3 months
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Loss of 6Kg or more (1st)
Loss of 3–5.9Kg weight loss ( ½–1st)
Loss of 0–2.9Kg weight loss (½ st)
No weight loss
Complicating health factors
-
Multiple or severe long-term conditions or infections, fractures or burns, cancer
Moderate infections, pressure sores/ulcers, digestive disorders, bereavement, depression
Minor infections, stroke, diabetes, alcohol problems
No complicating health factors
Score
Total score:
Score 6–14: High Risk – give assistance, specialist input from GP/dietician and specialist diet plan/products required,
record food/fluid intake, offer additional snacks/supplementary products, reassess weekly.
Score 4–5: Medium Risk – weigh weekly, record food/fluid intake for 3 days, offer additional snacks, encourage and
monitor, refer to GP if no improvement, reassess monthly.
Score 0–3: Low Risk – weigh monthly, reassess as required.
Part 3 – Nutritional Plan
This part of the assessment can be used to help to develop a nutritional/dietary plan for each service user.
Eating/drinking assistance/aids required:
Food/fluid intake monitoring:
Need to encourage eating/drinking:
Weight checks:
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Use of snacks/additional foods/fluids required:
Diet plan/special diet required:
Referral made to specialist/specialist involved:
Assessment completed by:
Designation:
Signed:
Dated:
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