Documentation/Dietary & Nutrition

Module guide · Clinical

Dietary & Nutrition

From the doctor's diet order to what actually lands on the tray and how much the patient eats, this module runs the full nutrition-of-care loop: screening, diet plans, the food catalog, and meal intake.

Overview Dashboard Diet plans Screenings & RD consults Food catalog Meal service & intake Good practices

What this module is for

Nutrition care starts with a risk screening, moves to a diet order (what the patient can eat, how, and why), draws from a shared food catalog tagged for allergens and diet compatibility, and ends with recording what the patient actually consumed.

Who uses it

Nurses run the initial nutrition screening and record meal intake. Physicians and Registered Dietitians (RDs) place and manage diet orders and consult notes. Kitchen/nutrition services staff maintain the food catalog.

Where to find it

Open Dietary & Nutrition from the sidebar. Five screens: a dashboard, diet plans, screenings & RD consults, the food catalog, and meal service & intake.

1
Screen
Within 24 hours of admission, a nutrition risk screening is recorded — it auto-computes BMI and % weight loss and assigns a risk level.
2
Order
A diet plan is created: diet type, texture, feeding route (oral, tube, or IV), and calorie/protein/fluid/sodium targets.
3
Serve
Kitchen staff draw from the food catalog, which is tagged for allergens and diet compatibility, and can be checked against a patient's allergy profile.
4
Track
Each meal's intake is recorded; the system rolls it up into a daily summary and flags patients eating critically below goal.

Dietary dashboard

An at-a-glance summary: who's on a special diet, who needs attention, and quick links into the other four screens.

Stat tiles

Field	What it means
Active Diet Plans	Currently active diet plans. Click through to Diet Plans.
NPO Patients	Patients currently on "nothing by mouth" orders. Click through to Diet Plans, filtered to NPO.
Enteral Nutrition	Patients being tube-fed. Click through to Diet Plans, filtered to enteral.
Parenteral (TPN/PPN)	Patients fed by IV, bypassing the digestive system. Click through to Diet Plans, filtered to parenteral.
Plans Expiring (3d)	Diet plans due to expire within 3 days.
Pending RD Consults	Screenings still waiting on a dietitian follow-up visit. Click through to Screenings.
High-Risk Screenings	Nutritional screenings flagged high risk. Click through to Screenings.
Critical Intake Alerts	Patients eating or drinking critically below their goal. Click through to Meal Service.
Temp Violations Today	Food-temperature safety violations recorded today, red if any, green if zero.

A bar chart below the tiles breaks down active diet plans by diet type. Four large tiles at the bottom link straight to Diet Plans, Screenings & Consults, Food Catalog, and Meal Service & Intake.

Diet plans

The doctor's or dietitian's nutrition order: diet type, texture, feeding route, and calorie/protein/fluid/sodium targets.

Quick filters and search

Field	What it means
All / NPO / Enteral / Parenteral	Quick-filter pills. Selecting NPO, Enteral, or Parenteral pulls a dedicated list and hides the Patient/Status filters below.
Patient search	Only shown under the "All" filter.
Status	Only shown under "All": All, or one of Draft, Proposed, Planned, Requested, Active, On Hold, Completed, Cancelled, Entered in Error, Unknown.

Table columns: Patient, Diet Type, Texture, Route, Status, Calories, Start date, RD. Click a row to open the plan's detail drawer.

"New Diet Plan" form

Field	What it means
Patient*
Ordering Provider*
Registered Dietitian	Optional.
Diet Type*	One of 39 options, e.g. Regular, Soft, Pureed, Diabetic / Carbohydrate-Controlled, Renal / Low Potassium-Phosphorus, Cardiac / Low Sodium, Gluten-Free, Nothing by Mouth (NPO), Enteral Tube Feeding, Total Parenteral Nutrition (TPN), Halal, Kosher, Vegan, Other / Custom.
Texture	Regular, Soft & Bite-Sized, Minced & Moist, Pureed, Extremely/Moderately/Mildly Thick, or Thin / Normal Liquids.
Feeding Route	Oral, Nasogastric Tube (NGT), Nasojejunal Tube (NJT), PEG, PEJ, Surgical Jejunostomy, Surgical Gastrostomy, IV Peripheral (PPN), IV Central (TPN/PICC), or Combination Enteral + Parenteral.
ICD-10 Indication	The diagnosis code justifying the order, e.g. "E43".
Indication Description
Calories (kcal) / Protein (g) / Fluid (mL) / Sodium Limit (mg)	Nutrient targets.
Start Date*	Defaults to today.
End Date
RD Notes / Physician Notes

Nutrition Calculators

A separate drawer for ad hoc math, not tied to a saved record: enter Height, Current Weight, Usual Weight, Age, and Gender, then Calculate to get BMI (with category), Ideal Body Weight, Estimated Energy Requirement (EER), and % Weight Loss, highlighted red if clinically significant.

In a plan's detail drawer: Activate, Hold (only from Active), Complete, or Cancel — each asks for a free-text reason. A FHIR button exports the order as a standards-compliant file. Every change is logged in an Audit History list.

Active — the order is in effect

Draft / Unknown — not yet finalized

Planned / Proposed / Requested — on the way to active, not started

On Hold — temporarily paused

Completed — the order ran its course

Cancelled / Entered in Error — voided

Screenings & RD consults

The Joint Commission requires a nutrition risk screening within 24 hours of admission. This screen records that screening and manages the dietitian follow-up it can trigger.

Three tabs: Pending RD Consults, Unsigned Consult Notes, and New Screening.

"New Screening" form

Field	What it means
Patient*
Screened By*
Height (cm) / Weight (kg) / Usual Weight (kg)	BMI and % weight loss are auto-computed from these.
Screening Tool*	NRS 2002, MUST, MNA, SGA, NUTRIC, PG SGA, SNAP, STRONGKIDS, or Custom.
Score
Risk Level*	No Risk, Low Risk, Moderate Risk, High Risk, or Critical / Severe.
Swallowing difficulty / Poor appetite / Recent surgery	Checkboxes.
RD consult required	Checkbox — adds this screening to the Pending RD Consults queue.
Notes

On a Pending RD Consults card: Create Consult opens a consultation-note drawer (Registered Dietitian required, plus Assessment, Nutrition Diagnosis/PES statement, Intervention, and Monitoring Plan), or Mark Done closes the requirement without a note. On an Unsigned Consult Notes card, Sign Note asks for your NPI to finalize it.

No Risk / Low Risk — no concern flagged

Moderate Risk — watch and reassess

High Risk / Critical — needs a dietitian consult

Food catalog

The master list of everything the kitchen can serve, with nutrition facts, allergen tags, and diet-compatibility tags.

Field	What it means
Search food items	Free-text keyword search.
Category filter	Free-text.

Table columns: Code, Name, Category, Kcal, Protein, Sodium, Diets (up to two compatible-diet badges plus an overflow count), Allergens (green "None" or red allergen badges).

"Add Food Item" form

Field	What it means
Item Code*
Name*
Category / Description
Calories, Protein, Carbohydrate, Fat Total, Sodium, Potassium, Fluid	Per-serving nutrition facts.
Gluten Free / Lactose Free / Vegan / Vegetarian / Diabetic OK / Renal OK / Cardiac OK	Checkboxes.
Compatible Diets	Tap to tag any of the 39 diet types this item is suitable for.
Allergens Present	Tap to tag any of: Milk, Eggs, Fish, Shellfish, Tree Nuts, Peanuts, Wheat, Soybeans, Sesame, Lactose, Fructose, Sorbitol, Sulfites, MSG, Corn, Nightshade, Other.

Patient Food Safety Check

Select a patient and the system cross-checks the catalog against their known allergy profile, listing only the items considered safe (green "Safe" badge). There's no "unsafe" list shown — anything that doesn't match simply isn't listed.

Export downloads the full catalog as CSV; Import bulk-loads items from a CSV file.

Meal service & intake

What the patient actually ate or drank at each meal, rolled up into a daily summary, with alerts for critically low intake.

Three tabs: Critical Intake Alerts, Patient Intake History, and Record Meal Intake.

"Record Meal Intake" form

Field	What it means
Patient*	Requires the patient to already have an active diet plan — otherwise the form is blocked with a note to create one on the Diet Plans screen first.
Recorded By
Meal Date	Defaults to today.
Meal Type	Breakfast, Mid-Morning Snack, Lunch, Afternoon Snack, Dinner, Evening Snack, Overnight Supplement, Tube Feeding, Oral Nutritional Supplement (ONS), or PRN / As Needed Snack. Defaults to Lunch.
Consumed %	0–100.
Appetite Level	Excellent, Good, Fair, Poor, or None. Defaults to Good.
Nausea / Vomiting / Refused meal	Checkboxes; checking Refused meal reveals a Refusal Reason field.
Notes

In Patient Intake History, pick a patient and a date range to see a daily Nutrition Intake Summary table (calories consumed/goal, % goal, protein, fluid, meals consumed/offered, and a status badge) plus a meal-by-meal history with appetite, % consumed, and warning icons for refusal or nausea/vomiting/choking.

Any patient currently below 50% of their intake goal shows up under Critical Intake Alerts; Acknowledge clears an alert once it's been addressed.

Adequate — meeting intake goal

Below Goal — under target but not critical

Critical — below 50% of goal — needs attention

Good practices

Screen first, order second

The intended order is screening → diet plan → meal intake. Meal intake can't even be recorded until an active diet plan exists for the patient.

Use the safety check before serving

The Food Catalog's Patient Food Safety Check cross-references allergens automatically, quicker and safer than checking a chart by hand.

Sign consult notes promptly

An unsigned RD consultation note isn't considered final, work the Unsigned Consult Notes tab down to zero.

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