Enteral Nutrition Documentation printable pdf download

Enteral Nutrition Documentation

Patient’s Name:

Date of Birth:

Medicaid ID #

Medical Diagnoses:

Method of feeds:

oral

NJ-tube

G tube

GJ tube

(need to qualify oral feeds)

Is patient unable to reach or maintain weight and

Yes

height at the 10

percentile for age and sex without

Please provide growth chart

supplemental feeding?

Does patient have a disease or dysfunction of the

Yes

digestive tract, including dysphagia, which causes

Describe:

nutritional deficiency with insufficient nutrients to

maintain body weight by impaired delivery of

nutrients to the small bowel?

Formula Name:

Total Volume for 30 days:

HCPC Code: ( on back)

Amount required to meet 100% of daily estimated

needs for one day, total Kcal/day______________

Anticipated length of time needed: _____months

Method of Administration:

*Must document reason of necessity for pump.

Check all that apply (attach medical/clinical documentation)

Syringe

Severe diarrhea

Gravity

Dumping syndrome

Pump* type:_________________________

Reflux

Describe how feeds are administered:

Aspiration

Continuous

Blood glucose fluctuations

Intermittent

Nissen

Bolus

Jejunal feeds

ombination

___________________

(explain)

Ventilated and/or trached

Feeding difficulties (oral aversions)

_______________________________________

Date: _______________

Time: _______________

signature

Statement of Medical Necessity:

__________________________________MD/LIP Contact #:_____________Date: ______________

Enteral Nutrition Documentation

Jan 09

Enteral Nutrition Documentation

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