Run Registered Dietitian Nutrition Assessment - SNF Admission & Change — Free

Assessment Context and Trigger

Assessment type documented critical (required)

Note (optional)

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.

Note (optional)

Relevant medical record reviewed critical (required)

Confirm review of current diagnosis list, recent progress notes, labs as available, diet orders, and nursing documentation relevant to nutrition status.

Yes No N/A

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.

Yes No N/A

Care team input obtained

Include input from nursing, therapy, speech-language pathology, or family/caregiver when needed to clarify intake, swallowing, or functional barriers.

Yes No N/A

Assessment date and time recorded

Assessment completed by registered dietitian critical (required)

Anthropometrics and Weight History

Current weight critical (required)

Note (optional)

Current height

Body mass index calculated

Note (optional)

Weight change over 30 days documented

Note (optional)

Weight change over 90 days documented

Note (optional)

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.

Note (optional)

Nutrition Intake and Diet Order

Current diet order matches clinical needs critical (required)

Verify ordered diet texture, fluid consistency, therapeutic restrictions, and any cultural or preference-based modifications.

Yes No N/A

Oral intake percentage documented

Note (optional)

Appetite status assessed

Note (optional)

Meal assistance needs identified

Note (optional)

Oral nutrition supplement use reviewed

Yes No N/A

Enteral or parenteral nutrition status reviewed

Yes No N/A

Hydration concerns identified

Yes No N/A

Food and fluid preferences documented

Yes No N/A

Nutrition-Focused Clinical Findings

Chewing or swallowing difficulty assessed critical (required)

Yes No N/A

Speech-language pathology referral indicated when needed

Yes No N/A

Gastrointestinal tolerance reviewed

Assess nausea, vomiting, diarrhea, constipation, abdominal pain, or early satiety that may affect intake.

Note (optional)

Pressure injury or wound burden reviewed critical (required)

Yes No N/A

Edema or dehydration signs assessed

Yes No N/A

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.

Yes No N/A

Medication effects on nutrition considered

Review medications that may affect appetite, taste, swallowing, bowel function, glucose control, or fluid balance.

Yes No N/A

Nutrition risk level assigned critical (required)

Note (optional)

Plan of Care and Follow-Up

Individualized nutrition diagnosis or problem statement documented critical (required)

Nutrition interventions selected critical (required)

Select all interventions included in the resident's plan of care.

Note (optional)

Monitoring parameters defined

Specify what will be monitored, such as weight trend, intake, wound healing, hydration, bowel pattern, or supplement acceptance.

Note (optional)

Follow-up frequency established

Note (optional)

Interdisciplinary communication completed

Document communication to nursing, provider, speech therapy, or family regarding nutrition concerns or plan changes.

Yes No N/A

Corrective actions initiated for urgent concerns critical (required)

Document any immediate actions taken for severe weight loss, dehydration risk, unsafe swallowing, or other urgent nutrition concerns.

Yes No N/A

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Run: Registered Dietitian Nutrition Assessment - SNF Admission & Change

Assessment Context and Trigger

Anthropometrics and Weight History

Nutrition Intake and Diet Order

Nutrition-Focused Clinical Findings

Plan of Care and Follow-Up

Get your results