Adult Malnutrition Assessment & Diagnosis Note (AND/ASPEN Criteria)

Note Type: Adult Malnutrition Assessment & Diagnosis Note (AND/ASPEN) | Date/Time: [Date and time] | Hospital Day: [HD#] | Location: [Unit/Bed] | Author/Credentials: [Name, credentials] | Reason for Consult: [Reason for consult]

Executive Summary

• Malnutrition status: [Severe malnutrition / Non-severe (moderate) malnutrition / At risk—insufficient criteria / No malnutrition identified / Unable to determine] (Diagnosis requires ≥2 of 6 AND/ASPEN characteristics.)
• Etiology/inflammation context: [Acute illness/injury-related / Chronic illness-related / Social/environmental-related / Mixed/unclear] (State clinical basis for category selection.)
• Clinical characteristics met: [Count] of 6: [Brief list of characteristics met with severity]
• Key quantified evidence: [Percent intake vs estimated needs with duration], [Weight loss percent with timeframe], [NFPE highlights]
• POA status: [Present on admission / Not present on admission / Unclear—needs provider clarification]
• Diagnosis recommendation: [One-line provider-facing recommendation summarizing severity, etiology, and key evidence]

Clinical Context & Etiology Classification

[Summary of admitting diagnosis, major active conditions, procedures impacting intake, and barriers to oral intake] (Include relevant clinical factors such as pain, sedation, mechanical ventilation, NPO status, dysphagia, GI dysfunction, or psychosocial access barriers.)

Etiology/inflammation category: [Acute illness/injury-related / Chronic illness-related / Social/environmental-related / Mixed/unclear] (State clinical basis for determination. Do not use albumin/prealbumin as nutrition status markers.)

Nutrition History

[Appetite changes and duration; typical intake prior to admission vs current intake; GI symptoms affecting intake; swallowing/chewing difficulties; functional feeding ability and assistance needs] (If history cannot be obtained, state "Unable to obtain because [reason]" and list any collateral sources used.)

Objective Nutrition Data

Anthropometrics & Weight

• Height: [Height and method/source]
• Current weight: [Weight, date, and method]
• BMI: [BMI value]
• Usual body weight (UBW): [Value, source, and date]
• Weight change: [Percent change with explicit timeframe] (Indicate if unintentional. Do not calculate if reliable weights unavailable.)
• Confounders: [Edema / ascites / diuresis / volume status changes / patient-reported weights / none]

Intake Assessment

• Current diet order: [Diet order]
• Oral intake estimate: [Meal intake percentage over timeframe]
• Oral nutrition supplements: [Type, frequency, acceptance] (Include only if applicable.)
• EN/PN: [Formula/solution, rate, kcal/protein provision, tolerance] (Include only if active.)
• Estimated needs: [Energy needs with method]; [Protein needs with method]
• Percent of needs met: [Percent of energy/protein needs met over stated timeframe]

Nutrition-Focused Physical Exam (NFPE)

• Subcutaneous fat loss: [None / Mild / Moderate / Severe] at [sites examined] (If NFPE not performed, state reason and do not assign fat loss.)
• Muscle loss: [None / Mild / Moderate / Severe] at [sites examined] (Do not infer without direct exam.)
• Fluid accumulation: [None / Mild / Moderate-Severe] at [locations] with likely etiology [etiology] (Differentiate nutrition-related vs disease-related fluid.)
• Exam limitations: [Patient factors limiting exam or areas not assessed / None]

Functional Status

• Handgrip strength: [Device, hand tested, result, comparison to norms] (If not measured, state reason.)

Pertinent Labs (Optional; for clinical context only)

• [Relevant labs such as CRP, electrolytes, micronutrients] (If albumin/prealbumin included, label as inflammation/illness markers, not nutrition status markers.)

AND/ASPEN Clinical Characteristics

(Document each characteristic. Do not infer findings or upgrade severity due to missing data.)

• 1. Insufficient energy intake: [Present / Absent / Unable to assess]; Severity: [Non-severe / Severe / N/A]; [Percent of estimated needs] for [duration]
• 2. Weight loss: [Present / Absent / Unable to assess]; Severity: [Non-severe / Severe / N/A]; [Percent loss] over [timeframe]; Unintentional: [Yes / No / Unclear]; Confounders: [confounders or none]
• 3. Loss of subcutaneous fat: [Present / Absent / Unable to assess]; Severity: [Mild / Moderate / Severe / N/A]; Sites: [sites examined]
• 4. Loss of muscle mass: [Present / Absent / Unable to assess]; Severity: [Mild / Moderate / Severe / N/A]; Sites: [sites examined]
• 5. Fluid accumulation: [Present / Absent / Unable to assess]; Severity: [Mild / Moderate-Severe / N/A]; Location: [locations]; Etiology: [etiology]
• 6. Diminished functional status: [Present / Absent / Unable to assess]; Handgrip: [result or reason not assessed]

Count of characteristics present: [Count] of 6 (≥2 required for diagnosis)

Assessment

[Determination statement: Meets malnutrition criteria / Does not meet criteria / Unable to determine due to missing data]. Severity: [Non-severe (moderate) / Severe] in the context of [etiology category]. (List the 2–4 strongest supporting characteristics with severity and quantified thresholds. Address confounders such as volume overload, diuresis, sarcopenia vs malnutrition, or measurement limitations as applicable.)

Diagnosis Statement for Medical Record

[Severity] protein-calorie malnutrition in the setting of [etiology category] due to [primary drivers], as evidenced by [characteristics with quantified thresholds and NFPE findings]. POA: [Yes / No / Unclear—needs provider clarification]. (Construct as a single ready-to-sign sentence. Include only if malnutrition criteria are met.)

Plan

• Interventions: [Diet modifications, ONS, EN/PN if indicated, micronutrient supplementation]
• Goals: [Measurable intake goals with timeframe], [Weight stability/target], [Functional improvement targets if applicable]
• Monitoring: [Intake documentation method and frequency], [Weight frequency], [Electrolyte monitoring if indicated], [NFPE reassessment interval]
• Care team communication: [Discuss diagnosis with primary team; request provider add malnutrition diagnosis to problem list]
• Refeeding risk: [Low / Moderate / High] (Include only if moderate/severe malnutrition with recent negligible intake.) Mitigation: [Thiamine supplementation], [Electrolyte monitoring frequency], [Caloric advancement strategy].

(For diagnostically critical elements—weight history, intake percentage, NFPE findings—document "Unable to assess/obtain because [reason]" rather than omitting. Never infer muscle or fat loss without NFPE, and never upgrade severity due to missing data.)