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Table 3.1. Sample Nutrition Report: High Risk

On-Time Quality Improvement Manual for Long-Term Care Facilities

Resident Name

Resident ID

Decreased Intake: First Date

Avg Meal Intake % Week 03/05/07

Avg Meal Intake % Week 03/12/07

Avg Meal Intake % Week 03/19/07

Avg Meal Intake % Week 03/26/07

TF

Weight Change Lb

A

001

03/26/2007

50

41

36

29

X

-1.5

B

002

03/27/2007

94

92

97

85

-

-3.3

C

003

03/29/2007

54

52

48

52

-

-1.5

D

004

03/31/2007

86

89

71

59

-

-10.5

* High risk = decreased meal intake and weight loss during the report week.

Decreased intake: first date = Date of the current week the resident first had meal intake of 50 percent or less for two meals in one day.

Average weekly meal intake = Average percentage of meals consumed for one full week, including breakfast, lunch, and dinner; takes into account missed meals, refusals, and NPO (nothing by mouth) status.

TF = Tube feeding. If resident is taking tube feedings, X will display.

Weight change in lb = Any weight loss during the report week. Determined by subtracting current week's weight from most recent weight.

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Current as of January 2011
Internet Citation: Table 3.1. Sample Nutrition Report: High Risk: On-Time Quality Improvement Manual for Long-Term Care Facilities. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/ontimeqimanual/qimanltab3-1.html