Normal narrative bank — stable / at-baseline
Each shows what was assessed, the objective finding, the baseline comparison, functional or safety relevance, skilled judgment, and reinforcement — edit to the actual visit.
N1 Adequate intake on therapeutic diet | Skilled nutritional assessment completed. The patient is following the prescribed low-sodium diet and reports intake at approximately 75–100% of meals with appetite at baseline; weight 168 lb, stable on the trend with no unintentional change. No malnutrition-risk indicators — no muscle wasting and no decline in intake. Chewing and swallowing are adequate for the diet; no GI symptoms limit intake. Findings indicate adequate nutrition on the prescribed diet. RN-level assessment was required to evaluate intake adequacy and diet adherence and screen for malnutrition risk against the weight trend given the diagnosis. Sodium label reading and the warning signs of declining intake reinforced; teach-back accurate. Continued skilled monitoring indicated. |
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N2 Enteral nutrition tolerated, site intact | Skilled nutritional assessment completed for a patient on enteral nutrition. The ordered formula is delivered at the ordered rate and tolerated, with no elevated residual and no nausea or distension; the gastrostomy site is intact, clean, and without erythema or leakage; the head of the bed is maintained at 30–45 degrees and the tube was flushed per protocol. Weight is stable. Findings indicate tolerated enteral feeding with an intact site. RN-level assessment was required to verify tolerance and the ordered rate, provide site care, and screen for complications. The caregiver demonstrated flushing and positioning; return demonstration accurate. Continued skilled monitoring indicated. |
N3 Diabetic diet adherence, weight stable | Skilled nutritional assessment completed. The patient is following the carbohydrate-consistent diet and reports consistent meal timing and portions with adequate intake; weight is stable on the trend. No malnutrition indicators; no GI symptoms limiting intake. Findings indicate adherence to the prescribed diet supporting glycemic management (parameters in the diabetes overlay). RN-level assessment was required to evaluate diet adherence and intake and screen for nutritional risk given the diagnosis. Carbohydrate consistency and the warning signs to report reinforced; teach-back accurate. Continued skilled monitoring indicated. (Glycemic parameters in the diabetes overlay.) |
N4 Recovering intake post-illness | Skilled nutritional assessment completed at the post-illness visit. Appetite and intake have improved from the prior visit, now at approximately 75% of meals, and the patient tolerates the prescribed diet; weight is stable after an earlier illness-related loss, with no further decline on the trend. No new wasting; no GI symptoms limiting intake. Findings reflect recovering nutritional status. RN-level assessment was required to confirm improving intake against the prior decline and screen for ongoing malnutrition risk. Fortification and small frequent meals reinforced to support recovery; teach-back accurate. Continued skilled monitoring indicated. |
N5 Texture-modified diet tolerated | Skilled nutritional assessment completed for a patient on a texture-modified diet per the IDDSI framework. The patient tolerates the prescribed texture with adequate intake and no coughing or wet voice during the observed portion of the meal; weight is stable. Findings indicate adequate intake on the prescribed texture. RN-level assessment was required to evaluate intake on the modified texture and screen for nutritional risk; swallowing mechanics are documented in the Taste / Swallowing reference. Safe-swallowing strategies and the prescribed texture reinforced with the caregiver; teach-back accurate. Continued skilled monitoring indicated. (Swallowing mechanics in the Taste / Swallowing reference.) |
N6 Stable nutrition with caregiver support | Skilled nutritional assessment completed. With caregiver support for shopping and meal preparation, the patient maintains adequate intake on the prescribed diet; weight is stable on the trend and there are no malnutrition indicators or GI symptoms limiting intake. Findings indicate adequate nutrition with the established support. RN-level assessment was required to evaluate intake adequacy, confirm the support plan meets needs, and screen for nutritional risk. The diet, warning signs, and the role of the caregiver in maintaining intake reinforced; teach-back accurate. Continued skilled monitoring indicated. |