Restorative Nursing Book LTCS Books www.LTCSBooks.com
Restorative Dining Evaluation
Resident_________________________________ Date______________________
Ability to Participate in Program
|
|
Adequate |
Mild impairment |
Severe impairment |
|
Cognitive |
|
|
|
|
Communication |
|
|
|
|
Sensory |
|
|
|
|
Range of Motion |
|
|
|
|
Dexterity |
|
|
|
|
Motivation |
|
|
|
|
Strength |
|
|
|
Therapy / Dietician consults dates/recommendations / Diet______________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Diet___________________________________________________ Weight_______
Average intake:
|
|
Food |
Fluids |
|
Breakfast |
|
|
|
Lunch |
|
|
|
Dinner |
|
|
Adaptive equipment presently used: ________________________________________
_____________________________________________________________________
Location where resident takes each meal:
|
|
Dining Room |
Resident Room |
Other |
|
Breakfast |
|
|
|
|
Lunch |
|
|
|
|
Dinner |
|
|
|
Restorative Dining Evaluation
|
Task |
Ability |
Assistance required |
|
Hold utensil |
|
|
|
Get food on utensil |
|
|
|
Pick up food with fingers |
|
|
|
Get food to mouth |
|
|
|
Reach items on tray/table |
|
|
|
Hold glass |
|
|
|
Open containers |
|
|
|
Eat without spilling |
|
|
|
Drink without spilling |
|
|
|
Cut meat |
|
|
|
Spread butter/jam on bread |
|
|
|
Season food |
|
|
|
Appropriate size of bites |
|
|
|
Maintain attention on meal to finish |
|
|
|
Use fork |
|
|
|
Chew food completely |
|
|
|
Swallow food |
|
|
|
Use napkin |
|
|
|
Finish food in reasonable time |
|
|
|
Remember mealtimes |
|
|
|
Identify foods on tray/table |
|
|
Notes:_______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Evaluation completed by_____________________________ Date_______________
Copyright © 2007 LTCS Books, Inc.
Call LTCS Books for all of your documentation needs 1-877-881-2404