| DIET |
| DIET/NUTRITION ORDERS |
| Diet Order | Date Started | Date Discontinued |
| High-energy, high-protein diet | Day 1 - admission orders |
| THERAPEUTIC DIET MENU |
| DIET | DIET | ||
| Normal diet | Gluten-free | ||
| Nil by mouth (NBM) | Lactose-free | ||
| Fluid restriction (specify): ________________________________ L/day | Low-lactose | ||
| Clear fluids | Low-amine | ||
| Diabetic clear fluids | Low FODMAPS | ||
| Free fluids | Low microbial | ||
| Thickened fluid (specify): ________________________________ | Texture modified food (specify): __________________Soft diet____ | ||
| No added salt (NAS) | Low fibre/low residue | ||
| Low protein | High fibre | ||
| Low potassium | High energy/high protein | ||
| Low protein, sodium, potassium | Low energy | ||
| Cardioprotective diet | Very low energy | ||
| Diabetic: Set CHO | Vegan | ||
| Diabetic: Modified CHO | Lacto-ovo vegetarian | ||
| Allergy (specify): Tuna - Presents with hives | Halal | ||
| Food intolerance (specify): ________________________________ | Kosher | ||
| FOOD SERVICE THERAPEUTIC DIET EXTRAS MENU |
| ABBREVIATION | FOOD | BF | MT | L | AT | D | S |
| Water | |||||||
| W | Water | ||||||
| ThW | Thickened water | ||||||
| SW/MW | Soda water/Mineral water | ||||||
| Milk Drinks | |||||||
| M | Whole milk | ||||||
| SKM | Skim milk | ||||||
| SyM | Soy milk | ||||||
| CM | Caramel milk | ||||||
| ChocM | Chocolate milk | ||||||
| ICoM | Iced coffee milk | ||||||
| SM | Strawberry milk | ||||||
| VM | Vanilla milk | ||||||
| Mo | Milo | ||||||
| TMo | Tetra Milo | ||||||
| TFM | Tetra Pak, flavoured milk | ||||||
| BSmth | Banana smoothie | ||||||
| Modified Milk Drinks | |||||||
| MP | Whole milk + polycose* | ||||||
| HPM | High-protein milk | ||||||
| ThMP | Thickened whole milk + polycose | ||||||
| LFM | Lactose-free milk | ||||||
| ThM | Thickened milk, + flavour code (AFC) | ||||||
| ThHPM | Thickened high-protein milk | ||||||
| ThLFM | Thickened lactose-free milk | ||||||
| ThMo | Thickened Milo | ||||||
| ThSyM | Thickened soy milk | ||||||
| Sodas/Soft Drinks | |||||||
| GAle | Ginger ale | ||||||
| Lmnd | Lemonade | ||||||
| LC | Lemon cordial | ||||||
| LimeC | Lime cordial | ||||||
| OC | Orange cordial | ||||||
| Modified Sodas/Soft Drinks/Cordial** | |||||||
| GAleP | Ginger ale + polycose | ||||||
| LmndP | Lemonade + polycose | ||||||
| LCP | Lemon cordial + polycose | ||||||
| LimeCP | Lime cordial + polycose | ||||||
| OCP | Orange cordial + polycose | ||||||
| DC | Diet cordial | ||||||
| ThDC | Thickened diet cordial | ||||||
| ThLCP | Thicknd lemon cordial + polycose | ||||||
| ThLimeCP | Thickened lime cordial + polycose | ||||||
| ThOrCP | Thicknd orange cordial + polycose | ||||||
| ThGAleP | Thickened ginger ale + polycose | ||||||
| ThLmndP | Thickened lemonade + polycose | ||||||
| Juices | |||||||
| AJ | Apple juice | ||||||
| OJ | Orange juice | ||||||
| PJ | Pear juice | ||||||
| PrJ | Prune juice | ||||||
| TJ | Tomato juice | ||||||
| Modified Juices | |||||||
| ThAJ | Thickened apple juice | ||||||
| ThOJ | Thickened orange juice | ||||||
| ThPJ | Thickened pear juice | ||||||
| ThPrJ | Thickened prune juice | ||||||
| Fruit and Sweets | |||||||
| IC | Ice cream | ||||||
| Cus | Custard | ||||||
| J | Jelly/Jello | ||||||
| DJ | Diet jelly/Diet jello | ||||||
| SyCus | Soy custard | ||||||
| Pru | Prunes | ||||||
| Modified Fruit and Sweets | |||||||
| ICP | Ice cream + polycose | ||||||
| CusP | Custard + polycose | ||||||
| PFr | Pureed fruit | ||||||
| PFrP | Pureed fruit + polycose | ||||||
| SyCusP | Soy custard + polycose | ||||||
| Yoghurts | |||||||
| Y | Yoghurt, flavoured | ||||||
| LFY | Low-fat yoghurt, flavoured | ||||||
| DY | Diet yoghurt, flavoured | ||||||
| FY | Portion frozen yoghurt, (AFC) | ||||||
| Cookies and Crackers | |||||||
| C/CC/CS | Crackers/C + cheese/C + spread | ||||||
| SW | Sweet wafers | ||||||
| SPC | Sweet plain cookies | ||||||
| ChCC | Chocolate-chip cookies | ||||||
| RC/RCS | Rice cakes/Rice cakes + spreads | ||||||
| GFC | Gluten-free cookies | ||||||
| Supplement Drinks | |||||||
| Bov | Bovril | ||||||
| CFS | Clear fluid soup (Consommé) | ||||||
| FS | Fortified soup | ||||||
| Ens (V/C) | Ensure (AFC) | ||||||
| FresE | Fresubin Energy (Vanilla) | ||||||
| Res (O/B) | Resource (Orange/Berry) | ||||||
| SusW | Sustagen + water (AFC) | ||||||
| SusSKM | Sustagen + skim milk (AFC) | ||||||
| SusM | Sustagen + whole milk (AFC) | ||||||
* Polycose or Polyjoule ** Cordial also known as squash AFC = Add the flavour code for the product
| BF | Breakfast |
| MT | Morning Tea/Morning Snack |
| L | Lunch/Midday Meal |
| AT | Afternoon Tea/Afternoon Snack |
| D | Dinner |
| S | Supper/Evening Snack |
| FOOD / FLUID CONSUMPTION CHARTS |
| Charts | Completed By: | Assessed By: |
| Day 1 - Food/Fluid Consumption Chart | Nurse | Dietitian |
| MALNUTRITION SCREENING TOOL |
| 1. Has the patient lost weight recently without trying? If yes, how much (kg)? |
2. Is patient eating poorly or lack of appetite. | Total Nutrition Score | |
|
No (0) Unsure if has lost weight (2) Yes: 0.5 – 5 kgs (1) Yes: > 5 – 10 kgs (2) Yes: > 10 – 15 kgs (3) Yes: > 15 kgs (4) Yes but unsure how much (2) |
Yes (1) No (0) |
3 | |
| Weight Loss Score: 2 | Appetite Score: 1 | ||
August Zuma
You conduct a PG-SGA to confirm your diagnosis. For the Physical Exam component of the PG-SGA (7. Worksheet 4 - Physical Exam) you note the following. Your examination findings are in red.
Fat Stores
| Orbital fat pads | 0 | 1+ | 2+ | 3+ |
| Tricep skin fold | 0 | 1+ | 2+ | 3+ |
| Fat overlying lower ribs | 0 | 1+ | 2+ | 3+ |
| Global Fat Deficit Rating | 2+ |
Muscle Status
| Temples | 0 | 1+ | 2+ | 3+ |
| Clavicles | 0 | 1+ | 2+ | 3+ |
| Shoulders | 0 | 1+ | 2+ | 3+ |
| Interosseous muscles | 0 | 1+ | 2+ | 3+ |
| Scapula | 0 | 1+ | 2+ | 3+ |
| Thigh (quadriceps) | 0 | 1+ | 2+ | 3+ |
| Calf (Gastrocnemius) | 0 | 1+ | 2+ | 3+ |
| Global Muscle Status Rating | 2+ |
Fluid Status
| Ankle edema | 0 | 1+ | 2+ | 3+ |
| Sacral edema | 0 | 1+ | 2+ | 3+ |
| Ascites | 0 | 1+ | 2+ | 3+ |
| Global Fluid Status Rating | 0 |
Score for 7. Worksheet 4 - Physical Exam - 2 Points
Find Link to SGA-form:
Updated October 20, 2025