Therapeutic Diet Order Recommendation Note

Date/Time: [Date and time]

Author: [Name, credentials, role/service]

Patient Location: [Unit/bed or care setting]

Attending/Ordering Clinician: [Name, credentials]

Reason for Consult: [Reason prompting diet recommendation request]

Recommendation Summary

(Use clear, order-ready language. If any recommendation is contingent on pending information, state the dependency.)

• Status: [Recommendation pending provider order / Order placed under author privileges per facility policy]
• Current diet order: [Exact current diet order name and specifications, or "None" or "NPO"]
• Proposed diet order: [Exact recommended diet order name and specifications; use facility-standard names and IDDSI terminology for textures/liquids]
• Time-sensitive constraints: [NPO timing, advancement schedule, re-evaluation triggers, pending dependencies] (Include only if applicable)
• One-line clinical rationale: [Concise reason for the change]

Clinical Indication

(Briefly anchor the recommendation to the clinical problem. Include only essential drivers.)

• [Primary diagnosis/condition(s) driving diet change]
• [Current care phase if relevant: post-op day, post-extubation, acute exacerbation]
• [Patient-centered constraints: preferences, cultural/religious needs, dentition, self-feeding ability] (Include only if applicable)

Current Intake and Orders

(Include only if there is a meaningful mismatch between orders and actual intake/tolerance; otherwise omit entire section.)

• Current diet/supplement orders: [Current orders or "Data not available"]
• Observed intake pattern: [Percent meals consumed, tolerance issues] (State "Data not available" if unknown)
• Barriers: [NPO for procedures, poor appetite, requires feeding assistance] (Include only if applicable)

Key Supporting Data

(Include only items directly justifying the recommendation. Omit entire section if not decision-critical.)

• Anthropometrics: [Weight/BMI with dates or trend direction] (Include only if relevant)
• Pertinent labs: [Glucose trends, Na/K/Phos/BUN/Cr with dates] (Include only if relevant)
• Relevant medications: [Insulin regimen, diuretics, binders] (Include only if relevant)
• Swallowing status: [Source evaluation type and date; IDDSI level recommendation] (Required for any texture/liquid modification; do not infer levels without documented evaluation)

Diet Order Specifications

(Provide only components being modified or that must be explicitly preserved. Use facility-standardized diet names and IDDSI levels.)

Base diet/pattern: [Regular / Cardiac / Carbohydrate-controlled / Renal / Other standardized diet name]

Carbohydrate specification: [Grams per meal; coordination with glucose checks and prandial insulin] (Include only if applicable)

Sodium restriction: [Numeric target and indication; temporary vs baseline] (Include only if applicable)

Potassium restriction: [Target level and indication] (Include only if applicable)

Phosphorus restriction: [Restriction level and indication] (Include only if applicable)

Texture-modified foods: [IDDSI Food Level number and label; source evaluation and date; safety qualifiers: supervision, pacing, positioning] (Include only if applicable; must cite source evaluation)

Liquid consistency: [IDDSI Drink Level number and label; source evaluation and date; safety qualifiers] (Include only if applicable; must cite source evaluation)

Fluid restriction: [Numeric limit in mL/day; what counts toward limit; duration; reassessment trigger] (Include only if applicable)

Allergies/intolerances: [Documented food allergies/intolerances]

Preference-based restrictions: [Cultural/religious/ethical dietary requirements] (Include only if applicable)

Supplements/nourishments: [Product name, frequency, timing] (Include only if part of plan)

Stop/reassess criteria: [Clinical changes that should trigger reassessment or diet advancement]

Justification

(Concise, neutral rationale linking diet components to condition, supporting data, and intended outcomes.)

• [Restriction/modification] justified by [clinical issue/lab/assessment] to achieve [intended outcome]
• [Additional justification as needed]
• [Tradeoffs or risks acknowledged; plan to monitor and adjust] (Include if applicable)

Education Plan

(Include when education is planned or provided. If deferred due to patient status, document reason and plan to revisit. Omit entire section if not applicable.)

• Learner(s): [Patient / Caregiver / Interpreter used]
• Topics: [Carb consistency, sodium label reading, fluid tracking, texture safety, etc.]
• Method: [Verbal / Handout / Demonstration / Teach-back]
• Patient response: [Teach-back accuracy; understanding demonstrated; barriers identified]
• Discharge/follow-up needs: [Outpatient referral, materials provided] (Include only if applicable)

Care Coordination

• [Attending/ordering clinician notified: method and response]
• [RN notified; instructions provided]
• [Food services/diet office notified] (Include only if applicable)
• [SLP notified] (Include only if texture/feeding safety involved)
• Recommendation status: [Accepted / Pending / Declined with reason]

Monitoring and Follow-Up

(Include when diet restriction introduces risk requiring surveillance; otherwise omit entire section.)

• [Intake adequacy: target and tracking method]
• [Glycemic monitoring plan] (Include only if carbohydrate-controlled)
• [Electrolyte monitoring schedule] (Include only if electrolyte-restricted)
• [Swallow tolerance monitoring and reassessment trigger] (Include only if texture-modified)
• [Planned reassessment date or condition-based trigger for diet advancement]

Signature

Author signature: [Electronic signature, credentials, service]

Order status: [This note represents a recommendation pending provider order / Order placed under author's privileges per facility policy]