A complete assessment addresses each of the following each visit, scaled to the patient's diagnosis and stability:
Dietary intake — adequacy relative to needs, recent change, appetite, and early satiety.
The prescribed therapeutic diet and adherence — for example low-sodium, carbohydrate-consistent, renal, or a texture-modified diet per the IDDSI framework.
Weight and the trend — unintentional loss or gain (measured and trended with Vital Signs).
Malnutrition risk indicators — the percentage and timeframe of unintentional weight loss, reduced intake, and visible muscle or fat wasting.
Chewing and swallowing ability as it affects intake (mechanics assessed in Taste / Swallowing).
Enteral nutrition, when present — tube type and placement, formula, rate, tolerance, and the insertion site.
Barriers to intake — food access and finances, dentition, cognition, function, and the ability to prepare meals.
GI symptoms affecting intake — nausea, vomiting, early satiety, or constipation; relevant nutrition-related labs per order.
