Royal Adelaide Hospital Clinical Nutrition Chart
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1
2PATIENT LABEL
ROYAL ADELAIDE HOSPITAL
AFFIX PATIENT LABEL
Unit Record No.: _________________________________
Unit Record No.
Ward
CLINICAL
Surname
Patient Name: ___________________________________
NUTRITION CHART
Given Names
Contact No: _____________________________________
Date of Birth
Sex
Age
of
Unit
CLINICAL NUTRITION CHART
of
Date: _____________________ Time: _______________
Date & Month
YEAR
DIETITIAN MUST ENTER ADMINISTRATION TIMES
REASON FOR NURSE NOT ADMINISTERING
Codes MUST be circled
Date
Product (Print full product name)
Container
Tick
if
A
Absent
ORAL
supplement
F
Fasting
Frequency. Enter times
Route
Method
Pump Rate
Dose (ml)
L
On Leave
ml/hr
Not available - obtain supply or
N
Signature
Print Name & Designation
Contact
Contact Dietitian
R
Refused - Notify Dietitian
Date
Product (Print full product name)
Container
Tick
S
Self Administered
if
ORAL
V
supplement
Vomiting— Notify Dietitian & Doctor
Dose (ml)
Frequency. Enter times
Route
Method
Pump Rate
Withheld— Enter reason in
W
Clinical Record
ml/hr
Signature
Print Name & Designation
Contact
FEED TUBE SPECIFICATIONS
TYPE and location
FRENCH
Date
Product (Print full product name)
Container
Tick
if
ORAL
SHAFT LENGTH
supplement
INSERTION DATE
Dose (ml)
Frequency. Enter times
Route
Method
Pump Rate
ml/hr
Signature
Print Name & Designation
Contact
ADDITIONAL CHARTS
Fluid Balance Chart
Date
Product (Print full product name)
Container
Tick
Nutrition Observation Chart (MR 124.0)
if
ORAL
Weight Chart (MR 104.0)
supplement
BGL Chart
Frequency. Enter times
Route
Method
Pump Rate
Dose (ml)
Food Intake Chart
ml/hr
Signature
Print Name & Designation
Contact
KEY FOR USE
The Clinical Nutrition Chart is for all enteral
nutrition & structured oral nutrition support .
The chart uses similar operating procedures
Date
Product (Print full product name)
Container
Tick
to the National Inpatient Medication Chart
if
(NIMC). Enteral & oral nutrition support is
ORAL
provided via your Clinical Dietitian.
supplement
DATE: date order was written.
Method
Pump Rate
Dose (ml)
Frequency. Enter times
PRODUCT: brand name in full (Jevity with
Route
Fibre, Jevity Hi Cal, Two Cal HN etc)
CONTAINER TYPE: Ready to Hang (RTH),
237ml can, 250ml tetra etc.
ml/hr
TICK IF ORAL SUPPLEMENT: clear identifica-
tion of oral vs enteral.
Signature
Print Name & Designation
Contact
ROUTE: NET, JEJ, PEG, Oral (PO) etc
METHOD: syringe, pump, gravity, oral
PUMP RATE: ml/hour for feed delivery via
pump.
DOSE: volume for each dose; ie med pass 50ml
Date
Product (Print full product name)
Container
Tick
dose x 4 (QID frequency), or 1000ml dose.
if
FREQUENCY: OD, BD, TDS, QID, Bolus,
ORAL
Continuous
supplement
TIMES: Times are written in adjacent vertical
column
Dose (ml)
Frequency. Enter times
SIGNATURE:Clinician’s signature
Route
Method
Pump Rate
PRINT NAME & DESIGNATION: Clear identifi-
cation of authorising clinician. May include:
Clinical Dietitian - all nutrition support
ml/hr
Medical Officer - NET insertion & length
documentation)
Signature
Print Name & Designation
Contact
Speech Pathologist - thickened fluid orders
CONTACT: Pager, mobile, speed dial (indicate)
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Parent category: Life