Nutrition

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DiraChart Clinical Reference
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1. Purpose and clinical relevance

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8. Interventions performed

Document the skilled interventions delivered this visit; each should connect to a finding and carry a reassessment in Section 10.

  • Nutritional assessment with malnutrition screening and interpretation of the weight and intake trend.
  • Therapeutic-diet teaching and reinforcement specific to the prescribed diet, with practical strategies.
  • Strategies to improve intake for at-risk patients — small frequent meals, fortification, and oral nutritional supplements per order.
  • Enteral-nutrition management per order — rate and flush, site care, and tolerance monitoring — where applicable.
  • Coordination of a dietitian referral, supplements, or laboratory studies per order, and mitigation of access or preparation barriers.
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