Nutrition Compass for Clinicians

Previous Visit Intervention & Monitoring Plan

Plan Narrative

Evaluation

Status

Barrier Tags

Summary

Reason for Visit

Health Concerns

Medical Diagnosis

No medical diagnosis imported

Medical History

Hospitalizations & Surgeries

Family Medical History

Health Condition Family Member Notes

Medications & Dietary Supplements

Medications

Supplements

Diet Orders

Medically Prescribed Diet

Nutrition Supports

Support Type Status Route Access Administration Method Formula & Product Name Formula Category Flavor Calories per mL Initial Rate Feedings per Day Amount per Administration Calories per Amount Administrations per Day Advance By Advance Every Goal Rate Infusion Time Free Water & Flush Total Daily Calories -- kcal/day Protein Fiber Free Water % Osmolality Nutrition Support Note

Medical Diet Note

Allergies & Intolerances

Allergies

Intolerances

Biochemical & Clinical Measurements

Laboratory Data

Date	Lab Test	Value	Unit	Source	Notes

Vital Signs

Date	Measurement	Value	Unit	Source	Notes

Anthropometrics

Date	Measurement	Value	Unit	Pct.	Z-score	Source

Anthropometric Assessment

Growth Velocity Z-score Trajectory Estimated Weight Loss Malnutrition Assessment Anthropometric Interpretation

Psychosocial Factors

Perceived Stress Level

0/10 Not Assessed

Perceived Stress Scale (PSS-10) *must request permission to use

Score: --/40

In the last month...

Questions 1-5

Score

1. How often have you been upset because of something that happened unexpectedly?

2. How often have you felt that you were unable to control the important things in your life?

3. How often have you felt nervous and stressed?

4. How often have you felt confident about your ability to handle your personal problems?

5. How often have you felt that things were going your way?

Questions 6-10

Score

6. How often have you found that you could not cope with all the things that you had to do?

7. How often have you been able to control irritations in your life?

8. How often have you felt that you were on top of things?

9. How often have you been angered because of things that happened that were outside of your control?

10. How often have you felt difficulties were piling up so high that you could not overcome them?

Emotional & Stress Barrier Tags

Substance Use

Psychosocial Note

Attitudes & Beliefs

Readiness to Change

0/10 Not Assessed Attitudes & Beliefs Note

Physical Health Factors

Sleep

Average Sleep Duration Sleep Quality Sleep Pattern

Energy Level

0/10 Not Assessed

Physical Activity

Oral Health

Dentition & Oral Status Mastication & Swallowing Oral Hygiene Routine

GI Health

Appetite Upper GI Symptoms Bowel Patterns

Nutrition-Related Physical Health Summary Physical Health Note

Food Access & Preparation

Food Security

USDA 6-item Food Security Module Last 12 months

Score: -/6 Complete all items to score

In the last 12 months...

1. Food did not last and there was not enough money to get more. Was that often true, sometimes true, or never true? 2. Balanced meals were not affordable. Was that often true, sometimes true, or never true? 3. Did you or your household ever cut the size of meals or skip meals because there was not enough money for food? 4. How often did this happen? 5. Did you ever eat less than you felt you should because there was not enough money for food? 6. Were you ever hungry but did not eat because there was not enough money for food?

Urgent Food Insecurity Tags

Meal Preparation & Cooking Ability Housing & Living Situation Transportation

Food Security & Environmental Barriers Note

24-Hour Dietary Recall

Breakfast Food & Nutrient Analysis

AM Snack Food & Nutrient Analysis

Lunch Food & Nutrient Analysis

PM Snack Food & Nutrient Analysis

Dinner Food & Nutrient Analysis

Bedtime Snack Food & Nutrient Analysis

Typical Intake

Beverages Desserts & Sweets

Dietary Recall Note

Calorie & Food Group Analysis

Estimated Intake Typical Dietary Pattern Estimated Calorie Level

Calorie Comparison

DAILY CALORIE INTAKE

Estimated -- kcal

Requirements 2000 kcal

Required Intake --

Food Group Comparison

VEGETABLES

Estimated Intake

Requirements cups/day 2.5 cups

Required Intake --

FRUITS

Estimated Intake

Requirements cups/day 2 cups

Required Intake --

GRAINS

Estimated Intake

Requirements oz eq/day 6 oz eq

Required Intake --

DAIRY

Estimated Intake

Requirements cups/day 3 cups

Required Intake --

PROTEIN FOODS

Estimated Intake

Requirements oz eq/day 5.5 oz eq

Required Intake --

Fluid Intake Analysis & Recommendations

Estimated Fluid Intake

= 1.8 L/day

Prescribed Fluid Intake

= 50.7 fl oz/day

Imperial Metric

Fluid Recommendation Output

Fluid Intake Comparison

Compare Fluid Prescription

DAILY FLUID INTAKE

Estimated Fluid Intake 1.8 L/day (60 fl oz/day)

Estimated Requirements 2.7 L/day (91.4 fl oz/day)

Calculated from age, sex, weight

Prescribed Fluid Intake 1.5 L/day (50.7 fl oz/day)

Required Fluid Intake vs Estimated Intake 67%

Fluid Prescription vs Estimated Intake 60%

Dietary Assessment Summary

Dietary Assessment Note

PES Builder

Problem

Etiology Signs & Symptoms

PES Statement Draft

Enter [Problem] related to [Etiology] as evidenced by [Signs & Symptoms].

Clinical Judgement Note

Diagnosis & Documentation Codes

Example Client

ADIME Note Builder

Monitoring & Evaluation

Assessment

Nutrition Diagnosis

Intervention

Monitoring & Evaluation