Nutrition-Focused Physical Exam (NFPE) Findings Note

Note title: [Nutrition-Focused Physical Exam (NFPE) Findings]

Date/time of exam: [Date and time]

Author: [Name], [Credentials: RD / RDN / CNSC / other]

Service/location: [Service or unit / clinic name and location]

Encounter context: [initial / follow-up]; [inpatient / outpatient]; [Reason for consult: malnutrition evaluation / poor intake / wound healing / micronutrient concern / other]

Exam Completeness and Limitations

[Exam completeness: complete / partial / not performed] (If partial or not performed, state reason.)

• [Barriers/limitations affecting exam validity] (Examples: limited mobility, pain, altered mental status, isolation precautions, dressings/casts/lines, inability to reposition, edema/anasarca, obesity, contractures, amputations.)
• [Patient declined portion(s) of exam] (Specify what was declined and stated reason, if provided. Omit if not applicable.)

Physical Findings

(Document objective observations first, then interpretation. Specify laterality and symmetry where relevant. Use standardized severity categories: None, Mild, Moderate, Severe. For any site not assessed, state "Not assessed" with the reason rather than leaving blank.)

Subcutaneous Fat Stores

• Orbital fat pads: [Observed appearance: normal fullness / hollowing / prominent orbital bones]; Severity: [None / Mild / Moderate / Severe]; [Laterality/symmetry]; [Confounders if applicable] (Or: Not assessed: [reason])
• Triceps/upper arm: [Observed pinch thickness/skin redundancy]; Severity: [None / Mild / Moderate / Severe]; [Laterality/symmetry]; [Confounders if applicable] (Or: Not assessed: [reason])
• Ribs/thoracic region: [Observed appearance: normal padding / visible ribs / loss of subcutaneous tissue along mid-axillary line]; Severity: [None / Mild / Moderate / Severe]; [Confounders if applicable] (Or: Not assessed: [reason])

Muscle Stores

• Temporalis: [Observed appearance: normal convexity / slight hollowing / marked hollowing]; Severity: [None / Mild / Moderate / Severe]; [Laterality/symmetry]; [Confounders if applicable] (Or: Not assessed: [reason])
• Clavicular region (pectoralis/deltoid/trapezius): [Observed appearance: normal fullness / prominent clavicle / reduced deltoid bulk]; Severity: [None / Mild / Moderate / Severe]; [Laterality/symmetry]; [Confounders if applicable] (Or: Not assessed: [reason])
• Shoulder/acromion: [Observed appearance: rounded contour / squared shoulders / protruding acromion]; Severity: [None / Mild / Moderate / Severe]; [Laterality/symmetry]; [Confounders if applicable] (Or: Not assessed: [reason])
• Interosseous (dorsal hand): [Observed appearance: normal fullness / depression between thumb and forefinger]; Severity: [None / Mild / Moderate / Severe]; [Laterality/symmetry]; [Confounders if applicable] (Or: Not assessed: [reason])
• Anterior thigh (quadriceps): [Observed appearance: rounded contour / reduced bulk / flatness]; Severity: [None / Mild / Moderate / Severe]; [Laterality/symmetry]; [Confounders if applicable] (Or: Not assessed: [reason])
• Posterior calf (gastrocnemius): [Observed appearance: normal fullness / reduced fullness / concavity]; Severity: [None / Mild / Moderate / Severe]; [Laterality/symmetry]; [Confounders if applicable] (Or: Not assessed: [reason])

Fluid Status

[Edema: present / absent]; Type: [pitting / non-pitting]; Location and grade: [feet / ankles / shins / sacral / generalized; grade per institutional standard]; Patient position at assessment: [supine / seated / standing] (Include if relevant to interpretation.)

[Ascites/abdominal distention: present / absent] (If present, describe extent.)

[Confounding statement] (If edema/ascites present, note potential to confound weight and BMI interpretation.)

Micronutrient-Related Signs

(Targeted findings based on patient history and risk factors. Document positive findings and clinically important negatives only. Frame findings as suggestive, not diagnostic; recommend correlation with labs and intake history.)

• Hair/scalp: [Positive findings with descriptor and location] (Suggestive of [nutrient deficiency]); [Pertinent negatives if assessed] (Or: Not assessed: [reason])
• Eyes: [Positive findings] (Suggestive of [nutrient deficiency]); [Pertinent negatives if assessed] (Or: Not assessed: [reason])
• Mouth/oral cavity: [Positive findings: gums, tongue, mucosa] (Suggestive of [nutrient deficiency]); [Pertinent negatives if assessed] (Or: Not assessed: [reason])
• Skin: [Positive findings with location and description] (Suggestive of [nutrient deficiency]); [Pertinent negatives if assessed] (Or: Not assessed: [reason])
• Nails: [Positive findings] (Suggestive of [nutrient deficiency]); [Pertinent negatives if assessed] (Or: Not assessed: [reason])
• Neuromuscular/sensory: [Positive findings: paresthesias, ataxia, weakness] (Suggestive of [nutrient deficiency]); [Pertinent negatives if assessed] (Or: Not assessed: [reason])

Functional Indicators

Handgrip strength: (If measured) Device: [device used]; Position: [patient position]; Hand tested: [dominant / non-dominant]; Trials: [number]; Values: [recorded values]; Interpretation: [interpretation vs facility norms] (Or: Not measured: [reason])

Observed functional cues: (If no formal test) [Relevant observations: difficulty with ADLs, inability to sit unsupported, low endurance, weak cough/voice] (Omit if not observed or not applicable.)

PT/OT/SLP results: [Referenced results and date] (Reference rather than duplicate if functional assessment performed by another service. Omit if not applicable.)

Summary and Clinical Significance

[2-4 sentence synthesis of most significant NFPE findings] (Highlight worst sites/patterns of muscle and fat loss, degree and distribution of fluid accumulation with confounding note, micronutrient signs that may alter management, and functional impairment if demonstrated.)

Nutrition Diagnosis Support

(Map NFPE findings to malnutrition characteristics. Do not assert malnutrition severity based on NFPE alone; NFPE supports the diagnosis alongside intake, weight, and inflammation context.)

• Subcutaneous fat loss: [Yes / No]; [Key sites if present]
• Muscle loss: [Yes / No]; [Key sites if present]
• Fluid accumulation: [Yes / No]; [Location(s) and grade if present]
• Diminished functional status: [Yes / No]; Method: [handgrip / observation / PT-OT results]

PES statement: [Problem] related to [Etiology] as evidenced by [Signs/Symptoms including NFPE findings] (Include only if facility uses PES format.)

Plan

• Intervention implications: [How NFPE findings inform nutrition care] (e.g., protein/energy escalation rationale, texture considerations based on oral findings, micronutrient repletion considerations, fluid/sodium strategy if edema prominent)
• Monitoring and reassessment: [Sites/domains to recheck] in [timeframe]
• Communication: [Team member/role notified], [when], [reason] (Omit if no communication required.)
• Recommended follow-up: [Labs, imaging, consults] (Omit if none recommended.)

Signature: [Name], [Credentials]

(NFPE findings reflect observations from the current encounter. If any content is carried forward, clearly label what was carried forward versus newly assessed.)