Royal Adelaide Hospital Clinical Nutrition Chart Page 2
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1
2Date & Month
FRONT PAGE
BACK PAGE
DIETITIAN MUST ENTER ADMINISTRATION TIMES
REASON FOR NURSE NOT ADMINISTERING
Codes MUST be circled
Date
Product (Print full product name & brand)
Container
Tick
SHORT TERM ENTERAL AND ORAL NUTRITION ORDERS
if
A
Absent
ORAL
supplement
TRANSITION FEEDING or DIETITIAN AUTHORISED TELEPHONE ORDERS
A
F
Fasting
Frequency. Enter times
Route
Method
Pump Rate
Dose (ml)
F
L
On Leave
L
Not available - obtain supply or
N
Dietitian Signature
Print Name
Contact
Contact Dietitian
DATE / MONTH
N
DIETITIAN MUST ADVISE ADMINISTRATION TIMES
& TRANSITION DATES
YEAR
R
Refused - Notify Dietitian
R
Date
Product (Print full product name)
Container type
Tick
S
Self Administered
if
S
ORAL
V
supplement
Vomiting— Notify Dietitian & Doctor
V
Dose (ml)
Frequency. Enter times
Route
Method
Pump Rate
Withheld— Enter reason in
W
Clinical Record
W
ml/hr
Signature
Print Name & Designation
Contact
FEED TUBE SPECIFICATIONS
ADDITIONAL CHARTS
TYPE and location
Fluid Balance chart
Weight Chart
FRENCH
Date
Product (Print full product name)
Container type
Tick
Nutrition Observation Chart
if
ORAL
BGL chart
SHAFT LENGTH
supplement
Food Intake Chart
INSERTION DATE
Dose (ml)
Frequency. Enter times
Route
Method
Pump Rate
ml/hr
References to relevant
Signature
Print Name & Designation
Contact
nursing docs re clear-
ADDITIONAL CHARTS
ing blocked tubes, how
Fluid Balance Chart
to measure NET length
Date
Product (Print full product name)
Container type
Tick
Nutrition Observation Chart (MR 124.0)
or just print generic
if
ORAL
how to info here—
Weight Chart (MR 104.0)
supplement
minimises double han-
BGL Chart
Frequency. Enter times
Route
Method
Pump Rate
Dose (ml)
dling and universal/
Food Intake Chart
state application.
ml/hr
Aspiration
Signature
Print Name & Designation
Contact
Bed angle
KEY FOR USE
Date of PEG / NET
The Clinical Nutrition Chart is for all enteral
insertion
nutrition & structured oral nutrition support .
The chart uses similar operating procedures
Type
Date
Product (Print full product name)
Container type
Tick
to the National Inpatient Medication Chart
if
(NIMC). Enteral & oral nutrition support is
Room temp
ORAL
provided via your Clinical Dietitian.
supplement
May benefit from short
DATE: date order was written.
stay + long stay ver-
Method
Pump Rate
Dose (ml)
Frequency. Enter times
PRODUCT: brand name in full (Jevity with
Route
Fibre, Jevity Hi Cal, Two Cal HN etc)
sions
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 type
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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