Registered Dietitian Nutrition Assessment - SNF Admission & Change

Comprehensive registered dietitian nutrition assessment for skilled nursing facilities on admission and significant change, including anthropometrics, nutrition risk, intake, and individualized care planning.

Assessment Context and Trigger

• Assessment type documented
• Assessment trigger clearly stated
  Document the clinical reason for this review, such as weight loss, poor intake, swallowing change, wound development, tube feeding, or acute illness.
• Relevant medical record reviewed
  Confirm review of current diagnosis list, recent progress notes, labs as available, diet orders, and nursing documentation relevant to nutrition status.
• Resident interview completed when feasible
  Document resident preferences, appetite concerns, food dislikes, and self-reported barriers to intake when the resident is able to participate.
• Care team input obtained
  Include input from nursing, therapy, speech-language pathology, or family/caregiver when needed to clarify intake, swallowing, or functional barriers.
• Assessment date and time recorded
• Assessment completed by registered dietitian

Anthropometrics and Weight History

• Current weight
• Current height
• Body mass index calculated
• Weight change over 30 days documented
• Weight change over 90 days documented
• Usual body weight documented
• Anthropometric data source verified
  Confirm whether weight and height were obtained from scale, bed scale, wheelchair scale, charted history, or estimated values.

Nutrition Intake and Diet Order

• Current diet order matches clinical needs
  Verify ordered diet texture, fluid consistency, therapeutic restrictions, and any cultural or preference-based modifications.
• Oral intake percentage documented
• Appetite status assessed
• Meal assistance needs identified
• Oral nutrition supplement use reviewed
• Enteral or parenteral nutrition status reviewed
• Hydration concerns identified
• Food and fluid preferences documented

Nutrition-Focused Clinical Findings

• Chewing or swallowing difficulty assessed
• Speech-language pathology referral indicated when needed
• Gastrointestinal tolerance reviewed
  Assess nausea, vomiting, diarrhea, constipation, abdominal pain, or early satiety that may affect intake.
• Pressure injury or wound burden reviewed
• Edema or dehydration signs assessed
• Laboratory indicators reviewed when available
  Document relevant labs such as albumin, prealbumin if used by facility policy, electrolytes, glucose, BUN/creatinine, or other nutrition-related markers.
• Medication effects on nutrition considered
  Review medications that may affect appetite, taste, swallowing, bowel function, glucose control, or fluid balance.
• Nutrition risk level assigned

Plan of Care and Follow-Up

• Individualized nutrition diagnosis or problem statement documented
• Nutrition interventions selected
  Select all interventions included in the resident's plan of care.
• Monitoring parameters defined
  Specify what will be monitored, such as weight trend, intake, wound healing, hydration, bowel pattern, or supplement acceptance.
• Follow-up frequency established
• Interdisciplinary communication completed
  Document communication to nursing, provider, speech therapy, or family regarding nutrition concerns or plan changes.
• Corrective actions initiated for urgent concerns
  Document any immediate actions taken for severe weight loss, dehydration risk, unsafe swallowing, or other urgent nutrition concerns.