Nutritional Diagnosis Form

(ICD-9* Nutritional Services)

Patient name: _____________________________________ Room number: ______________

Height: _____________ Admission weight:______________ BMI: ___________________

Diagnosis: __________________ Date of initial nutritional assessment: ________________

Attending physician:____________________________________________________________

Adult Patient’s BMI

Adult patient’s BMI is considered:
▪ 278.02 Overweight (BMI of 25-29)
– V85.21 BMI 25-25.9
– V85.22 BMI 26-26.9
– V85.23 BMI 27-27.9
– V85.24 BMI 28-28.9
– V85.25 BMI 29-29.9
▪ 278.00 Obesity, unspecified (BMI of 30-39)
– V85.30 BMI 30-30.9
– V85.31 BMI 31-31.9
– V85.32 BMI 32-32.9
– V85.33 BMI 33-33.9
– V85.34 BMI 34-34.9
– V85.35 BMI 35-35.9
– V85.36 BMI 36-36.9
– V85.37 BMI 37-37.9
– V85.38 BMI 38-38.9
– V85.39 BMI 39-39.9
▪ 278.01 Morbid Obesity
– BMI ≥40 (V85.4)
– BMI ≥35, with (V85._______) with medical complications of:
□ Kwashiorkor/protein malnutrition (260)
□ Nutrition marasmus (261)
□ Severe protein-calorie malnutrition
□ Mild-degree malnutrition
□ Moderate-degree malnutrition
□ Unspecified protein-calorie malnutrition

Pediatric patient’s BMI†

Pediatric patient’s BMI is considered:
– V85.51 BMI <5th percentile
– V85.54 BMI ≥95th percentile
Nutritional assessment: ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Plan of care: ________________________________________________________________

______________________________________________________________________________
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Short-term goals:____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Recommended diet prescription modification (if applicable): _________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Dietitian’s name (print): _____________________________________________________

Dietitian’s signature: ________________________________________________________

Date: _____________________

Physician note: ______________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Physician’s name (print): ____________________________________________________

Physician’s signature: _______________________________________________________

Date: ____________________

*ICD-9 is the International Classification of Diseases, 9th revision, Clinical Modification, 6th
edition, issued for use beginning October 1, 2007, for federal fiscal year 2008. The ICD-9-CM
is maintained jointly by the National Center for Health Statistics and the Centers for Medicare
& Medicaid Services.
†
BMI pediatric codes are for use for persons ages 2-20. These percentiles are based on the
growth charts published by the Centers for Disease Control and Prevention.

Review Date 7/08

G-0688