How to write a nutritional assessment: A Complete Guide

Knowing how to write a nutritional assessment is tough. Especially when every RD does it a little differently. So how do you know what to write and how to write it? This is your complete guide to organizing and writing nutritional assessments.

How to Write a Nutritional Assessment: A Complete Beginners Guide

Writing a nutritional assessment note as a new dietitian, can be tricky.

Every RD seems to write them differently. Which means getting a straight answer on how to get them done can feel almost impossible.

While each facility will have it’s own assessment template built in to their EMR, writing the summary at the end of a nutritional assessment is one of the most important skills you can have as a new RD.

To make writing these notes as easy as possible for you, use this complete guide on writing clear and simple nutrition notes.

It’s divided into 2 parts.

Part 1: Structure of a nutritional assessment
Part 2: Phrasing in a nutritional assessment

In this post you’ll:

See what a real-life nutrition note example can look like
Learn exactly how to break that down and do it for your patients
Get a cheat sheet with easy phrases that will keep your notes clear, concise, and well written

Let’s get started with maybe the most common questions about writing nutrition notes.

PART 1: STRUCTURE OF A NUTRITIONAL ASSESSMENT

Why do nutrition notes always look different?

Before you look over an example, let’s be clear about this one very important fact: Every nutritional assessment will look different.

There are two reasons for this.

First, each facility will have a template posted in their EMR that’s special to that facility.

This means the information you’re asked to focus on might vary between each place you work.

Part of this is the difference between acute care, long-term care, and writing personal notes for your private practice.

But it’s also a matter of style.

And this brings us to the second reason nutritional assessment notes can look wildly different.

When writing their final free-form summary, every RD will use a slightly different structure and set of phrases they prefer.

The content might be robust or minimal. The sentences might be long and complete, or short and abbreviated.

Finding your style is part of becoming a great dietitian.

How to summarize a nutritional assessment note?

Let’s be clear before we dive in.

The purpose of this post is not to instruct you on the only way to write a note.

The point is to give you an easy-to-follow starting place that will always work when you’re feeling overwhelmed by all the possibilities.

Because there is nothing more frustrating than sifting through a medical note you KNOW has the information you need but is buried on a single line that’s taken you seven minutes to find.

No one has time for that, least of all dietitians.

Instead, let’s build nutrition notes that are quick to write and easier to read.

Writing strong nutrition assessments comes down to doing each of these things, in all your notes:

Identify all the topics you consider important to successfully caring for your patient or resident.
Outlined what’s happening with them or the reason you were tasked to see them.
State clearly what you are prioritizing for them.

What do clear and concise notes look like?

Before we dive in, I want you to remember this one thing.

No matter how a preceptor or a professor tells you they want you to write a note, there’s no wrong way to do this.

Every dietitian has a writing style special to just them.

And as you write more notes, you’ll start to develop your own voice and cadence in your notes.

You’ll decide what to focus on and have phrasing you’ll use over and over again to illustrate that point.

Let’s take a look at what a free-form admission note can look like once you’ve assembled all the information you need to complete an assessment.

NOTE: This was written for long-term care. But the components will stay the same in acute care, even if the content and phrasing vary a bit.

EXAMPLE NUTRITIONAL ASSESSMENT NOTE:

Pt is an 80 yo woman recently D/C from hospital s/p UTI leading to sepsis. PMH of lymphedema, spinal fx, PVD, Afib, HTN, R+L leg cellulitis, osteoarthritis, Fe def, MLD, B12 def, constipation, mitral valve insufficiency, heart disease, zinc def, Ca def, GERD, cirrhosis, hiatal hernia, h/o gastric bypass.

Stage 3 R+L buttock PIs, improving per RN 1/27 note. Cellulitis with infected L-leg stasis wounds noted per chart review. 2+ B/L LE edema noted.

Abx for wound infection continues, diuretic started for fluid retention. No new labs avail.

Continues on a cardiac diet with variable intake of 25-75% intake per caregiver doc.

CBW on admit: 245.2 lb. Last avail wt on 10/4/22: 222.7 lb, 22.5 lb / 9.2% wt gain x 3 months, significant. Pt reports UBW of ~200 lb x 1 year, significant and insidious wt gain noted.

NFPE indicates decreased lean muscle mass in calves, upper arms. High risk for malnutrition noted.

Add Prostat 20 ml TID + Juven BID to aid in continued wound healing. Recommend providing additional 240 ml fluids q shift and encouragement during meals to support adequate intake.

Food preferences discussed. Will include Ensure TID, and daily tuna sandwich with lunch to support improved intake and decrease current malnutrition risk.

Goals: no significant wt gain x 90 days, no s/s dehydration, improved skin integrity, intake 75%< of all meals/ONS.

Continue with weekly wts x 4 weeks, will adjust dietary interventions PRN. Will follow skin integrity, intake, wt status, labs as avail. Care plan updated.

What are the parts of this nutrition note summary?

You’ve probably seen something like this a million times already.

Let’s break this down so you can start to replicate it.

Although a standard assessment has a few distinct parts to it, each facility will have a different format they’ll ask you to follow.

PRO TIP: Don’t feel like just because you aren’t familiar with that specific way of writing that you don’t know what you’re doing.

It’s going to be an adjustment wherever you go. And that’s ok.

Just remember these basic parts and follow the assessment template they give you.

The structure of all nutrition notes will have each of these parts, mixed and matched as necessary.

Let’s go through each part of the above assessment and look at what’s included.

1. Who and what (M/F, age, admitting diagnosis, PMH)

This is where you’re introducing the person you’re talking about and providing an overview of everything they’re going through. It can look like this:

You’ll see this sort of header in almost all formal medical assessments, most of the time cut and pasted by whichever doctor wrote it first.

It’s usually only for reference but when you’re rushing to remember who has what, it’s handy when you know it’s ALWAYS at the top of your full notes.

2. Pertinent medications, skin integrity, notable lab values

Here you’re building a bridge between what’s happening medically and the nutritional issues you’ll be talking about.

Stage 3 R+L buttock PIs, improving per RN 1/27 note. Cellulitis with infected L-leg stasis wounds noted per chart review. 2+ B/L LE edema noted. Abx for wound infection continues, diuretic started for fluid retention. No new labs avail.

Some people list every medication and lab value provided. Others include only the ones they’re going to address in their interventions.

But when it comes to wounds, you MUST be clear if their skin is intact and how you know this (ex: skin intact per 1/14 wound care note) or exactly what kind of breakdown they have and where you got that information.

3. Weight status, current diet order, ONS, or additional supplements

Now you’re starting to outline the nutritional concerns and interventions that you’ve touched on in the last couple of sections.

Continues on a cardiac diet with variable intake of 25-75% intake per caregiver doc.

CBW on admit: 245.2 lb. Last avail wt on 10/4/22: 222.7 lb, 22.5 lb / 9.2% wt gain x 3 months, significant. Pt reports UBW of ~200 lb x 1 year, significant and insidious wt gain noted. NFPE indicates decreased lean muscle mass in calves, upper arms. High risk for malnutrition noted.

Even though you might not be making a change or highlighting a recommendation until the next couple of sentences, you’re still setting the stage for them.

If anyone has questions about why you’re making the nutritional recommendations you’re making, they’ll likely find the justification for those in this section.

4. Recommendations and interventions

This is where you’re being firm about what your patient or resident needs and how you’re going to support them.

Add Prostat 20 ml TID + Juven BID to aid in continued wound healing. Recommend providing additional 240 ml fluids q shift and encouragement during meals to support adequate intake.

Food preferences discussed. Will include Ensure TID, and daily tuna sandwich with lunch to support improved intake and decrease current malnutrition risk.

If they need an ONS, say what it’s going to be and why they need it. Or if they have food preferences, put them here. If the diet order is inappropriate and it needs to be changed, make a note of that adjustment (ex: Cardiac diet in place. DM with elevated glu levels noted. Diet changed to CCD, low Na)

5. Goals, follow-up plan

And finally, state your follow-up plan. Make sure to note why you’re doing something if it’s at all unclear.

Goals: no significant wt gain x 90 days, no s/s dehydration, improved skin integrity, intake 75%< of all meals/ONS.

Continue with weekly wts x 4 weeks, will adjust dietary interventions PRN. Will follow skin integrity, intake, wt status, labs as avail. Care plan updated.

This will look different in acute care. But the basic information remains the same. You want to be clear about what needs to happen (your nutritional goals for them) and when they’re expected to be completed (a follow-up statement).

This is by no means the only way to write a nutritional assessment.

Some dietitians ONLY write their goals and interventions in the final comment box at the end of a full note.

However, a complete note like this makes sure you’ll never lose track of important information. And any other RD coming behind you to treat this person will know exactly what you did and why you did it.

Without having to sift through a seven-page nutrition note just to figure out a diet order or why someone’s getting extra protein.

The benefits of summarizing your note in this way include:

A consistent place where anyone reading your note can find all relevant information.
A single area to read pertinent nutrition information, rather than scrolling through a sometimes very lengthy assessment template.
Information that’s easy to copy and paste or reference when you need to use that information in another place, like going from an admission note to a progress note.

What isn’t in this summary nutrition note?

You might notice that PES statements weren’t included in this free-form nutrition note.

There’s no special reason for this.

If you want PES statements in your nutrition note, go for it.

Everything in your PES statements should also be written in your free-form note.

What you include in this final note is completely up to you as a registered dietitian and health care professional.

And as long as you have all the relevant information in the full assessment, you can format this last summary note in any way you want.

You have a voice specific to you. You’ll develop a style that’s yours alone. It might take time but remember there are no wrong answers.

But what can help is remembering this structure.

And then use some simple phrases to help keep your notes short, to the point, and easy to understand.

Let’s get into a cheat sheet to get you started writing clear and concise notes you can be proud of.

PART 2: PHRASING IN A NUTRITIONAL ASSESSMENT

How can you keep your nutrition note concise?

When becoming a dietitian, you spend a lot of time reading scientific studies.

Writing expertly written papers.

Ensuring your grammar is in proper form.

But writing nutritional assessments and summarizing your notes is when you’re going to forget all of that.

Instead of full sentences and precise grammar, opt for word abbreviations and short sentences.

And although you can write your notes in any way you see, these are the kinds of shortcuts you’ll find yourself using over and over.

Let’s take a look at some common phrasing that can help you write simpler notes, faster.

COMMON PHRASES

Let’s start with taking the personal out of your notes.

Skip the complete sentences that begin with My patient has… or I noticed that…

Instead, start your sentences with what’s happening with your patient as in Pt notes… or Pt reports.

Providing context:

These can go at either the beginning or end of a sentence. They’re used to indicate where you got specific information from, so you’ll never have to search for it again.

Per WHO + date note (ex: place at the start or end of a sentence, per 1/8 RN note)
WHO reports (ex: RN reports poor intake over last week / Pt reports poor appetite x 1 week)
As discussed with (ex: Recommend decreasing Ensure from 4x/day to BID, as discussed with RN)

Writing out weight status:

A lot of writing about weights comes down to abbreviations and stylistic choices. Here are some ideas.

Wt status (Instead of: weight status)
Wt change x LENGTH OF TIME (Too long: My patient reports noticing a weight loss of 5 lbs since his last doctor’s appointment on 1/14. Better: Pt reports 5 lb wt loss x 1 month)
Therapeutic wt change (To be specific about a loss or gain that is MD recommended)
Intentional wt change (To be clear about a loss or gain being patient-driven)
Beneficial or Favorable (Can also be used as: wt gain is not beneficial or further wt loss is not favorable)
Significant and Nonsignificant (For clarity about a weight change)

Identifying important items:

There are times you just need to identify that something is a fact. These make those statements easy.

Noted (ex: Noted h/o weight loss or Recent non-significant h/o weight loss noted)
In place (ex: Multiple diuretics in place)
Continues with (ex: Continues with wound vac, abx in place for ongoing wound infection)
Fluctuations
Currently on or remains on

Making your recommendations:

The phrasing for your recommendations and interventions will likely depend on the facility you work in. Some places encourage dietitians to add their own orders, other places require outreach to RNs or MDs for approval before you can see an order in place.

Choose your words based on what is appropriate for the facility you work in. Here are some common ones to pick from.

Current dietary interventions remain appropriate.
Consider
Recommend
Receiving
To support
Remains with
Will follow as avail
Will update as avail

And That’s It!

We covered how to structure a nutritional assessment as well as phrases to use to write it quickly and simply.

Feel like you need more than just a blog post? Check out:

Clinical Bootcamp for a full rundown on doing clinical nutrition in the real world
Clinical Text Support to get immediate answers to your clinical questions while you’re at work and short on time
Private Coaching for tutoring in MNT, interview prep and career counseling

Want even more to help in clinical?
Check out The Nutrition Cheat Sheets Shop for all the nutrition education and clinical resources that will make your life easier.