Sta cL Clit ia Lt MG ADIME Audit Form NUTRITION ASSESSMENT: Does the Assessment follow the IDNTT guidelines for writing an assessment including: (Note: all sections may not be required in all assessments) a) Food/Nutrition-Related History b) Biochemical Data, Medical Tests, & Procedures ¢) Anthropometric Measurements d) Nutrition Focused Physical Findings e) Client History Yes No (PES Statement) No Appropriate comparative standards used? &) No. NUTRITION DIAGNOSIS: [Assessment includes info that is succinct, relevant eo to support the nuttition diagnosis Yes Was a nutrition problem/diagnosis identified based on selected data available? Gs) No Is there initial documented evidence in the Assessment porto: note to support « nutrition ere Ys) No ay All 3 components of PES statement present using, —o y(R/T) and signs/symptoms (AEB). =) No Diagnosis uses exact NCP terminology? No Etiology is root cause that RD can resolve or reduce signs/symptoms. @) No INTERVENTION: ‘A nutrition prescription is written that supports the nuttition and identifies goals that are ‘measurable, achievable and time-defined. Yes No The intervention is ditected at changing the etiology but H\aot possible to change etiology, itis directed at reducing the impact of signs/ symptoms. Yes No GOAL Is patient’s goal related to the documented plan for an intervention ot actual intervention? Yes) No MONITORING AND EVALUATION: M/E, component addresses the nutrition (Yes No