Formulir Asuhan Gizi [PDF]

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RM 28 DK



FORMULIR ASUHAN GIZI Tanggal Diagnosa Medis



: :



Resiko Rendah (Nilai MST 0) Resiko Sedang (Nilai MST 1) Resiko Tinggi (Nilai MST ≥2) Pasien mempunyai kondisi khusus Ya sebutkan............... Tidak ASSESMEN GIZI Antropometri Umur : BB : BB/U : TB : BB/TB : LILA : IMT/Z-score : Status Gizi : Biokimia Klinis/ Fisik



Riwayat Gizi Alergi makanan *Telur *Susu Sapi & Olahannya *kacang kedelai/tanah *Gluten/Gandum



Ya



Tidak



Ya



Tidak



*Udang *Ikan *Hazelnut/almond



Pola makan :....................................................................................................................................... ............................................................................................................................................................ ............................................................................................................................................................ Riwayat Gizi Recall Makanan Pasien Kebutuhan Gizi Energi : kkal Energi : kkal Karbohidrat : gr Karbohidrat : gr Protein : gr Protein : gr Lemak : gr Lemak : gr Riwayat Gizi ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................ DIAGNOSIS GIZI



INTERVENSI GIZI Tujuan Intervensi : Intervensi makanan : 1. ............................................................ Cara pemberian : 2. ............................................................ Lewat mulut 3. ............................................................ Lewat pipa MONITORING



Bentuk makanan : Biasa Lunak Saring Sonde Puasa EVALUASI



Ahli Gizi (....................)