M & M HOME CARE: REGISTERED DIETITIAN VISIT NOTE

1Treatment > 2Billing & Signature > 3Review Your Entry
PATIENT NAME PATIENT NAME First Last
PATIENT DOB: PATIENT DOB: / MM / DD YYYY
TREATMENT DATE: TREATMENT DATE: / MM / DD YYYY
TREATMENT STARTED TREATMENT STARTED : HH MM AM/PM
TREATMENT ENDED TREATMENT ENDED : HH MM AM/PM
LOCATION OF TREATMENT

LOCATION OF TREATMENT HOME VISIT (12) OFFICE VISIT (11) TELEHEALTH-IN HOME (10) TELEHEALTH-NOT IN HOME (02)
SUBJECTIVE

Information provided by patient or family of signs & symptoms, lifestyle pattern, etc.
OBJECTIVE
DIET ORDER
SUPPLEMENTS/SNACKS
HEIGHT
WEIGHT
B/P
PULSE
RESPIRATION
SpO2
BEHAVIORAL ASSESSMENT
PRESENTATION:

PRESENTATION: ALERT / ORIENTATED ANXIOUS LETHARGIC APATHETIC NON-COMPLIANT COMATOSE DISTRACTED TANGENTIAL PERSEVERATIVE DIS-INHIBITED NEURO-FATIGUED OTHER OTHER
NUTRITIONAL HABITS:
CULTURAL/DIET RESTRICTIONS:
PAIN
FREQUENCY OF PAIN

FREQUENCY OF PAIN 0 - HAS NO PAIN 1 - HAS PAIN THAT DOES NOT INTERFER WITH ACTIVITY OR MOVEMENT 2 - LESS OFTEN THAN DAILY 3 - DAILY BUT NOT CONSTANT 4 - ALL OF THE TIME
INTENSITY OF PAIN
QUALITY OF PAIN

QUALITY OF PAIN Shooting Sharp Electric Hot Radiating Aching Heavy Dull Cramping Throbbing Other Other
PAIN SITE(S)
AGGRAVATING FACTORS
ALLEVIATING FACTORS
SKIN
NO DEFICIT
WOUND PRESENT
IF WOUND PRESENT - PROVIDE DESCRIPTION
Warm Hot Cold Cool Dry Clammy Diaphoretic Other Other
SAFETY
FALL PRECAUTIONS MAINTAINED?

FALL PRECAUTIONS MAINTAINED? YES NO UNKNOWN
ANY FALLS SINCE LAST VISIT?

ANY FALLS SINCE LAST VISIT? YES NO UNKNOWN
ANY MEDICATION CHANGES SINCE LAST VISIT?

ANY MEDICATION CHANGES SINCE LAST VISIT? YES NO UNKNOWN
ANY SIGNIFICANT HEALTH CHANGES SINCE LAST VISIT?

ANY SIGNIFICANT HEALTH CHANGES SINCE LAST VISIT? YES NO UNKNOWN
IF "YES" TO ANY OF THE ABOVE - PLEASE DESCRIBE:
ENTERAL NUTRITION
Pump Gravity Bolus
ADEQUACY OF NUTRITIONAL INTAKE
CALORIES:
PROTEIN:
FREE WATER:
OTHER WATER:
TOTAL WATER INTAKE:
100% US RDA
PARENTERAL NUTRITION
% DEXTROSE SOLUTION
VOLUME ML
% AMINO ACID SOLUTION
GRAMS OF PROTEIN
% FAT
FAT GRAMS
CALORIES
NUTRITIONAL SUPPLEMENTS

(g/ml as applicable)
NUTRITIONAL ADDITIVES

Vitamins, minerals, probiotics, amino acids, co-enzyme Q10, omega 3, herbals, etc (IU; g/d; mg/d).
NUTRITIONAL ASSESSMENT
FOOD SENSITIVITY OR ALLERGY?

FOOD SENSITIVITY OR ALLERGY? YES NO
If yes, please describe below.
UBW RANGE
IBW RANGE
BMI
PATIENT TEACHING
PATIENT RESPONSE TO THERAPY / TEACHING
INDIVIDUALIZED CARE PLAN
EQUIPMENT PROVIDED TO PATIENT
ANY EQUIPMENT PROVIDED TO PATIENT THIS VISIT?

ANY EQUIPMENT PROVIDED TO PATIENT THIS VISIT? YES NO
IF SO, WHAT WAS PROVIDED & WHY:
COMMUNICATION
COMMUNICATION WITH:

COMMUNICATION WITH: SN PT OT SLP CASE MGR HHA FAMILY OTHER OTHER
COMMUNICATION REGARDING:
PHYSICIAN COMMUNICATION
PHYSICIAN CONTACTED:
DATE DATE / MM / DD YYYY
TIME TIME : HH MM AM/PM
ORDER CHANGES
PLAN FOR NEXT VISIT
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M & M HOME CARE: REGISTERED DIETITIAN VISIT NOTE

M & M HOME CARE: REGISTERED DIETITIAN VISIT NOTE

SUBJECTIVE

OBJECTIVE

BEHAVIORAL ASSESSMENT

PAIN

SKIN

SAFETY

ENTERAL NUTRITION

ADEQUACY OF NUTRITIONAL INTAKE

PARENTERAL NUTRITION

NUTRITIONAL SUPPLEMENTS

NUTRITIONAL ADDITIVES

NUTRITIONAL ASSESSMENT

PATIENT TEACHING

PATIENT RESPONSE TO THERAPY / TEACHING

INDIVIDUALIZED CARE PLAN

EQUIPMENT PROVIDED TO PATIENT

COMMUNICATION

PHYSICIAN COMMUNICATION

PLAN FOR NEXT VISIT