Nutrition Care Plan
Eve Betterhalf, Sr.
Patient Identifiers
444222222 United States Social Security Number
example-vendor-id OID: 2.16.840.1.113883.19

About

Date of Birth
05/1/1975
Sex
Female
Race
Ethnicity

Contact

Home

2222 Home Street 3333 Old Home Street

Beaverton, OR

97867, US

Tel : +1(555)555-2003

Emergency Contact

Mrs. Martha Jones

Contact

17 Daws Rd.

Ann Arbor, MI

97857, US

Tel : (999)555-1212

Care provision

Consultation for transition of care from 11/1/2016 to 12/1/2016

Service Event

Claude Dietitian, RDN
11/1/2016 - 12/1/2016

Author

Registered Dietician, RDN

Contact

1004 Diet Drive

Portland, OR

99123, US

Tel : +1(555)555-1004

Encounter

Identifier
9937012 OID: 2.16.840.1.113883.19
Type
Consultation
Date
From: 12/1/2016, 09:20
To: 12/1/2016, 10:20
Location
ID: NPI-Example United States National Provider Identifier

Responsible Party

Michael Coletta, M.D. of Mass Nutrition

Contact

2100 North Ave

Burlington, MA

02368, US

Tel : +1(555)555-1003

Assigned entity

Review of Care Plan

Assigned entity {$code/@code='SELF'?}

Review of Care Plan

Care giver

Mrs. Martha Jones

Contact

17 Daws Rd.

Ann Arbor, MI

97857, US

Tel : (999)555-1212

Informant

Harold Foodie, CPh

Contact

1007 Diet Drive

Portland, OR

99123, US

Tel : +1(555)555-1003

Information Recipient

Nutrition Coordinator, RDN

Contact

100 Better Health Rd.

Ann Arbor, MI

97857, US

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Legal authenticator

Nutritionist Registered of Greater Area Care signed at 12/1/2016

Contact

1004 Diet Drive

Portland, OR

99123, US

Tel : +1(555)555-1004

Health Concerns Section

Nutrition Diagnosis
Excessive Caloric Intake

Goals Section

Goal Referencing
Reduce Calorie intake to 1900 calories/day Nutrition diagnosis of excessive Caloric Intake

Interventions Section

Planned Interventions
  • Type Details Date Restricted Items
    Nutrition Statement/Prescription Ketogenic diet 2017-08-03
    Nutrition Order Order for protein supplement 2017-08-04
    Nutrition Order: Enteral

    Adult diabetic specialty formula administered through Nasogastric route

    • Adult diabetic specialty formula (product)
    • Route: nasogastric
    • Product: Adult diabetic specialty formula
    • Total Formula Amount: 320 g

    Feeding Instructions

    • Frequency: 4 times/day, Every 6 hours
    • Feeding Amount: 80 g
    		 2017-08-03 to 2017-08-04
    Nutrition Order: Enteral

    Enteral Administration through Nasogastric route

    • 80g Protein + Consistent Carb
    • 2g Sodium
    • 2g Potassium
    • 900mg Phosphorus
    • 1500mL Fluid Restricted
    		 2017-08-03 to 2017-09-22 Red meat
Interventions Performed

Health Status Evaluations/Outcomes Section

Date Observation Supporting Evidence Progress towards goal Related Goal Associated Intervention
2017-08-03 Estimated fat intake currently 200% of nutrition prescription 10 meals/week with hamburgers and fries No progress towards goal

Signed

Eve Everywoman at 12/1/2016

Contact

Primary Home

2222 Home Street

Beaverton, OR

97867, US

Tel : +1(555)555-2003

Document maintained by

Greater Area Nutrition Care HIE

Contact

Work Place

1009 Diet Drive

Portland, OR

99123, US

Tel : +1(555)555-1009

Entered by

Ellen Enter

Contact

1007 Diet Drive

Portland, OR

99123, US

Tel : +1(555)555-1050

Document Information

Document Identifier Document Created
OID: db734647-fc99-424c-a864-7e3cda82e703 12/1/2016, 11:20