Name of individual Date of completion C B A Nutrition Able to take adequate food and drink by feeding to ensure adequate intake of Dysphagia requiring skilled intervention to mouth to meet all nutritional requirements. food and takes a long time (half an hour or ensure adequate nutrition/hydration and OR more), including liquidised feed. minimise the risk of choking and aspiration to Needs supervision, prompting with meals, OR maintain airway. or may need feeding and/or a special diet Unable to take any food and drink by OR (for example to manage food mouth, but all nutritional requirements are Subcutaneous fluids that are managed by the intolerances/allergies). being adequately maintained by artificial individual or specifically trained carers or care OR means, for example via a non-problematic workers. Able to take food and drink by mouth but PEG. OR requires additional/supplementary feeding. Nutritional status risk’ and may be ‘at associated with unintended, significant weight loss. OR Significant weight loss or gain due to an identified eating disorder. OR Problems relating to a feeding device (e.g. PEG) that require skilled assessment and review.
Name of individual Date of completion C B A Nutrition Able to take adequate food and drink by mouth to meet all nutritional requirements. OR Needs supervision, prompting with meals, or may need feeding and/or a special diet (for example to manage food intolerances/allergies). OR Able to take food and drink by mouth but requires additional/supplementary feeding. feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidised feed. OR Unable to take any food and drink by mouth, but all nutritional requirements are being adequately maintained by artificial means, for example via a non-problematic PEG. Dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to maintain airway. OR Subcutaneous fluids that are managed by the individual or specifically trained carers or care workers. OR Nutritional status ‘at risk’ and may be associated with unintended, significant weight loss. OR Significant weight loss or gain due to an identified eating disorder. OR Problems relating to a feeding device (e.g. PEG) that require skilled assessment and review.