Nutrition Support Smart Phrase Example

Enteral Feeding Formula & Equipment Initial Order:

Diagnosis related to need for enteral nutrition:***

DME Company Name:***

DME Company Fax #:***

Patients Estimated Daily Nutrient Needs:

kcals/day:***

protein/day:***

fluid/day:***

fiber/day:***

Other:***

Name of Formula: ***

If specialized formula, why? ***

Ok to use equivalent formula? Yes No

Calories from formula per day (kcals)): ***

Protein from formula (grams): ***

Free water from formula (mL): ***

Fiber from formula (grams):***

Other nutrients from formula:***

Method of Administration:

Syringe/Bolus Gravity Pump

Route of Administration:

NG NJ Gastrostomy Tube Jejunostomy Tube G/J Oral Tube Size: ***

If using pump, infusion rate: *** ml/hr x ***hours daily

Reason for pump: ***

If bolus/gravity/syringe: *** mL *** times per day

Free water given in divided amounts: ***

Every 8 hours Before and after each feeding Before and after each medicine Other (***)

Modifiers (if any): ***

Functional Impairment (what is preventing food from reaching the gut? what is preventing nutrients from being absorbed?): ***

If no functional impairment, what is the reason that patient requires enteral support? ***

Permanence of Need: Need is expected to be for a prolonged (but indeterminate) time period or Permanent.

MD must document in note length of need and functional impairment requiring tube feeding.

Enteral Feeding Formula & Equipment Change Order:

Diagnosis related to need for enteral nutrition:***

DME Company Name:***

DME Company Fax #:***

Patients Estimated Daily Nutrient Needs:

kcals/day:***

protein/day:***

fluid/day:***

fiber/day:***

Other:***

Current formula: ***

Amount of current formula being used: ***

Calories from current formula per day (kcals)): ***

Protein from current formula (grams): ***

Free water from current formula (mL): ***

Fiber from current formula (grams):***

Other nutrients from current formula:***

Additional oral intake: ***

Recommended changes to tube feeding: