Fillable Disability Resource Hub Disclaimer (New South Wales)

Fill Online, Printable, Fillable, Blank Disability Resource Hub Disclaimer (New South Wales) Form

Use Fill to complete blank online NEW SOUTH WALES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Disability Resource Hub Disclaimer (New South Wales)

On average this form takes 399 minutes to complete

The Disability Resource Hub Disclaimer (New South Wales) form is 103 pages long and contains:

  • 75 signatures
  • 135 check-boxes
  • 1234 other fields

Country of origin: AUSTRALIA
File type: PDF

Australia forms for New South Wales

BROWSE NEW SOUTH WALES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Disability Resource Hub Disclaimer
The material on the Disability Resource Hub is for reference only. No claim or
representation is made or warranty given, express or implied, in relation to any of the
material. You use the material entirely at your own risk.
The material is provided as point-in-time reference documents. FACS does not
maintain the material and does not undertake to ensure that it is accurate, current,
suitable or complete.
Where conditions and warranties implied by law cannot be excluded, FACS limits its
liability where it is entitled to do so. Otherwise, FACS is not liable for any loss or
damage (including consequential loss or damage) to any person, however caused
(including for negligence), which may arise directly or indirectly from the material or the
use of such material.
Nutrition and Swallowing
Procedures Tools and templates
Summary: The Nutrition and Swallowing Procedures tools and templates provide resources
to be completed when supporting a person with good nutrition and safe swallowing.
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
2
Tools and templates
Nutrition and Swallowing
1. My Eating and Drinking Profile
2. Nutrition and Swallowing Risk Checklist
3. Mealtime Management Plan – Oral Only
4. Enteral Nutrition Plan – Nil by Mouth
5. Enteral Nutrition Plan – Plus Oral Intake
6. Food Diary
7. Monitoring Daily Healthy Eating and Exercise
8. Menu Planning Checklist
9. Healthy Food Group Shopping List
10. Food Safety Kitchen Equipment Checklist
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 3
My Eating and Drinking Profile
• Complete for a person who eats a normal diet as per Australian dietary standards. Where the person requires a modified diet
or utensils, they must be referred to an allied health professional by their GP.
• Refer to the Nutrition and Swallowing Procedures for guidance in completing the My Eating and Drinking Profile.
My details
Insert my photo
My name
Date I was born
I like to be called:
My CIS number:
My TRIM number:
Where I live
My phone number
People who helped me
create my profile
Creation / review
date
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 4
Signature(s) My signature
My allergies and medication
In RED CAPITAL LETTERS, list any food allergies here:
Describe any food allergy related PRN medications I have been prescribed:
All PRN medication must be administered as per GP or specialist’s recommendations.
Refer to medication charts for medication preparation and timing.
Describe any special support I require for receiving medication:
click to sign
signature
click to edit
click to sign
signature
click to edit
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 5
My food and drink preferences
The food I like and dislike
I like
I dislike
Breakfast: Breakfast:
Lunch: Lunch:
Snacks: Snacks:
Dinner: Dinner:
The drinks I like and dislike
I like
I dislike
Breakfast: Breakfast:
Lunch: Lunch:
Snacks: Snacks:
Dinner: Dinner:
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 6
My religious and cultural food / drink preferences
Food
Drink
Equipment
Item Describe how I use the item
My usual eating and drinking
equipment
Cutlery
Plate / bowl
Cup / glass
Clothes protector
Other
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 7
How to assist me
Usual way Describe how I eat:
Independent
Assisted
Sit / stand beside me
Left side
Right side
Sit / stand facing me
Other – describe:
Alertness & seating
I should always be alert and awake before I eat or drink.
Describe below whether I have a special chair to sit in to eat meals:
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 8
How to supervise me to eat and drink safely
The supervision I require to keep me
and others safe
I require supervision while eating or drinking
No
Yes If yes, describe: e.g. 1:1 or line
of sight
I will try to grab food or fluids
No
Yes If yes, describe:
I will try to re-distribute food or fluids
No
Yes If yes, describe:
The time I usually take to eat my
meal is
Breakfast: Snacks:
Lunch: Drinks:
Dinner: Other:
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 9
My favourite atmosphere
Creating the best
atmosphere for me
Where do I like to sit for meals?
(e.g. dinner table, certain spot at table,
outside for lunch when possible)
The people I like to sit with
Other things I have preferences for
Lighting
Noise levels
Furniture layout
Table setting
Other
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 10
My communication style and behaviour
I have a Communication Profile Yes
No
Comment:
How I usually act
before, during and after
mealtimes
e.g. show excitement, anticipation, agitation, impatience, specific intolerances, alertness
Before meals
During meals
After meals
This is how I show
I am full
I would like more
food or drink
I need someone to
help me
What I do like
What I do not like
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 11
How I like to be actively supported to participate
I like to participate in
Menu planning: Please describe how I like to be offered choices and how I communicate my
decisions / preferences
Activity Describe how I like to participate in this activity
Make a grocery list
Shopping
Setting the table
Clearing the table
Unpacking shopping
Organising the pantry
Food preparation & cooking
Wash up / load dishwasher
Wipe bench tops
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 12
How I like to be actively supported to participate
Sweep / vacuum
dining area floors
Other activities
My preferences for eating out
What atmosphere do I prefer
when eating out?
Few people Quiet environment Many people Loud environment
Describe:
What support items do I need to
take?
Utensil
Clothing
protector
Modified plate
Modified cup
Plate guard
Thickener /
nutrition
supplements
Special food
Medication Webster-Pak
®
PRN (e.g. EpiPen
®
)
Other – describe:
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 13
My preferences for eating out
How do I prefer to communicate
Do I use a communication device? Yes No
If yes, the communication device is located at:
Yes If yes, describe how I use it with people and how I like to be supported to use it.
How do I order my meal?
How do I like to pay for my meal?
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 14
My favourite meals when eating out
My favourite meals
Describe:
My favourite drinks
Describe:
Favourite venues
Describe:
Getting there
Describe how the person travels to the venue: (e.g. public transport, vehicle etc.)
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 15
This is how it looks to support me to eat my meals in the best way possible.
Use this area to
add
photographs of
the person
which shows
the best way to
support them to
enjoy their
meal in a safe
and nutritious
manner.
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 16
Nutrition and Swallowing Risk Checklist
Instructions
What is the purpose of the Checklist?
• The Nutrition and Swallowing Risk Checklist (the Risk Checklist) is a way of
screening people for difficulties related to nutrition and swallowing. It cannot make
a diagnosis of a medical condition. A diagnosis can only be made by a health
specialist.
• The Risk Checklist was developed as a means of raising awareness of nutrition
related problems in people with disability. It has been developed to be used by
people who care for people with disability.
• By asking questions about a person’s health, weight and their ability to eat and
drink, the checklist will determine if further assessment and action is needed,
including advice or assessment by a dietitian, speech pathologist or other health
professional.
Who should complete it?
• If you are completing the Risk Checklist you should know the person with a
disability well. You may be the case manager or support worker. Collaboration with
a parent or family member may be helpful in achieving the most accurate result.
• Include the person with disability when completing the Risk Checklist.
How to complete it
Part 1 – Preliminary Profile - Gathers and evaluates information about the person’s
weight and height. In this section you have to write in the information requested for
some questions and tick the relevant box for others.
Part 2 – Nutrition and Swallowing Risk Checklist - Assesses if the person has
indications of nutritional problems or swallowing difficulties that may affect their
nutrition and health. Tick the relevant box for each question.
Part 3 – Summary of Results - Records descriptions of the risks or issues of
concerns relating to questions answered with a ‘Yes’ or ‘Unsure / Do not know’. The
GP should review the Summary of Results and prescribe action to be taken in the
shaded ‘Further Action Required’ column.
Do not guess answers
• Try to obtain all the information you need to complete the Risk Checklist. For
example, you may need to look at the person’s weight records to work out if they
have lost or gained weight over the past three months. If there are no records and
you are not able to measure height or weight, you should still complete as much of
Part 1 as you can, and then complete Part 2 to the best of your knowledge.
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 17
• Be observant. Do not guess answers. Use your powers of observation to answer
questions about how the person eats and drinks. If you are unsure or do not know
the answer to a question, you may need to seek a line manager’s opinion. If the
answers are still uncertain, tick the ‘Unsure / Do not know’ box and refer to a health
professional for assistance.
Part 1 – Preliminary Profile
The Person Name:
Gender: Male Female
Date of birth: Age:
CIS no.: TRIM no.:
Person responsible:
Address:
This address is: an independent residence
a family home
a supported accommodation service
other: specify ___________________________
Has the Risk Checklist been used before for this person? Yes
No
If ‘Yes’, enter date when last Risk Checklist completed:
Person completing the
Risk Checklist
Name:
Signature:
Date Checklist completed:
Relationship to the person:
support worker
case worker
nurse
parent
other (specify) __________________________
How long have you known
the person?
less than 6 months
6 months – 1 year
1-2 years
2-5 years
more than 5 years
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 18
Part 1 – Preliminary Profile
Where is the Risk Checklist
being completed?
the person’s home
the person’s school
the person’s work
a District office
Who is the person providing
the information – so you can
complete this Risk
Checklist?
(tick more than 1 box if
needed)
self
the person
parent
close relative
close friend
other (specify) ____________________________
Weight information Current weight without shoes: (kg) _______________
Refer to Section 3.3 in the Nutrition and Swallowing Guidelines for information
about accurately measuring a person’s weight.
Date measured:
If you have no information about the person’s
weight – why not?
Weight change over the
past 3 months:
gained
lost
Do you have weight records for the past 3
months?
Yes No
Height information
Current height standing without shoes (cm)
________.
Refer to Section 3.4 in the Nutrition and Swallowing Guidelines for information
about accurately measuring a person’s height.
If you have no information about the person’s
height, or are unable to measure their height –
why not?
Children
For children and young people aged under 18 years,
their growth rate should be assessed by a GP,
paediatrician, early childhood nurse or dietitian every
year.
Has this happened? Yes No
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 19
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 20
Using the weight and height information:
If the person is an adult, mark the spot on the chart below where their height and
weight meet.
Weight for Height Chart
Calculate the person’s BMI:
1. Access the website: http://www.mydr.com.au/tools/bmi-calculator.
2. Enter the person’s height in centimetres.
3. Enter the person’s weight in kilograms.
4. Click on ‘Calculate BMI’ and enter below.
The person’s BMI:
The person’s weight and height must be recorded in their Weight Chart.
Where the GP or specialist has provided a specific weight chart or assessment tool
instead of the BMI, complete the chart and attach to the Risk Checklist.
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 21
Part 2 Nutrition and Swallowing Risk Checklist
Tick an answer box for each question. The explanations beneath each question and
the Nutrition and Swallowing Procedures references will help you complete the
checklist. There are 24 questions.
Question 1
If the person is a child, (i.e. under 18 years of age) have
they lost weight or failed to gain weight over the last
three months?
Not applicable
Yes
No
Unsure / Do not know
Question 2
Is the person underweight?
Tick the ‘Yes’ box if either of the following apply:
The person is an adult and their weight on the
Weight for Height Chart is in the ‘underweight’ or
‘very underweight’ range;
When you look carefully at the person (adult or
child), their bone structure is easily defined under
their skin. This can indicate significant loss of fat
tissue and is easily checked by looking around
the person’s eyes and cheeks. Other areas to
check include the shoulders, ribs and hips.
Yes
No
Unsure / Do not know
Question 3
Has the person had unplanned weight loss or have they
lost too much weight?
Tick the ‘Yes’ box if any of the following apply:
The person’s weight loss is undesirable or has
been unexpected;
The person is under 18 years of age and there is
weight loss in two or more consecutive months;
The person has lost weight in two or more
consecutive months and is not on a monitored
weight loss program.
Yes
No
Unsure / Do not know
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 22
Question 4
Is the person overweight?
Tick the ‘Yes’ box if either of the following apply:
The person is an adult (i.e. over 18 years of age)
and their weight on the Weight for Height Chart is
in the overweight or obese range;
The person (adult or child) appears to have rolls
of body fat.(e.g. around the abdomen)
Yes
No
Unsure / Do not know
Question 5
Has the person had unplanned weight gain or have they
gained too much weight?
Tick the ‘Yes’ box if either of the following apply:
The person’s weight gain is undesirable or has
been unexpected;
The person is not on a weight gain program and
their clothes no longer fit.
Yes
No
Unsure / Do not know
Question 6
Is the person receiving tube feeds?
Tick the ‘Yes’ box if the person is receiving naso-
gastric, naso-duodenal or gastrostomy feeding.
Yes
No
Unsure / Do not know
Question 6a
If you answered ‘Yes’ to question 6, does the person
also receive food or drink through the mouth?
Tick the ‘Yes’ box if the person receives any food or
drink by mouth, in addition to tube feeding.
If the person is receiving tube feeds and no other food
by mouth, then answer only questions 10, 13, 14, 16,18
and 19.
Not applicable
Yes
No
Unsure / Do not know
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 23
Question 7
Is the person physically dependent on others in order to
eat or drink?
Tick the ‘Yes’ box if:
The person cannot put food or drink into their
own mouth and someone else is needed to feed
them;
The person is dependent on assistance during a
meal (e.g. guidance with utensils).
Yes
No
Unsure / Do not know
Question 8
Has the person had a reduction in appetite or food or
fluid intake?
Tick the ‘Yes’ box if either of the following apply:
The person is not eating or drinking as much as
they usually do and this is unintentional;
The person appears unwilling to take most food
offered to them and the equivalent of six large
glasses of fluid each day.
Yes
No
Unsure / Do not know
Question 9
Does the person follow, or are they supposed to follow,
a special diet?
Tick the ‘Yes’ box if they are on, or are supposed to be
on, any of the following dietary plans:
Pureed, minced, chopped or soft foods;
Thickened fluids;
Weight reduction or weight-increasing;
Low fat;
Vegetarian;
Low cholesterol or cholesterol-lowering;
Diabetic;
Any other diet which modifies or restricts foods or
food choices.
Yes
No
Unsure / Do not know
click to sign
signature
click to edit
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 24
Question 10
Does the person take multiple medications?
Tick the ‘Yes’ box if:
The person is usually on more than one type of
medication.
Yes
No
Unsure / Do not know
Question 11
Does the person select inappropriate foods or behave
inappropriately with food?
Tick the ‘Yes’ box if any of the following apply:
The person over-consumes alcohol or coffee, tea
and cola drinks;
The person eats non-food items such as dirt,
grass or faeces;
The person drinks excessive amounts of fluid;
The person steals or hides food.
Yes
No
Unsure / Do not know
Question 12
Does the person usually exclude foods from any food
group?
Tick the ‘Yes’ box if the person usually excludes all
foods from one or more of the following groups of food:
Bread, cereals, rice, pasta, noodles;
Vegetables, legumes;
Fruit;
Milk, yogurt, cheese;
Meat, fish, poultry, eggs, nuts, legumes.
Yes
No
Unsure / Do not know
Question 13
Does the person get constipated?
Tick the ‘Yes’ box if either of the following apply:
The person’s bowel movements are irregular,
painful and sometimes infrequent;
Laxatives, suppositories or enemas are required
to maintain regular bowel movements.
Yes
No
Unsure / Do not know
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 25
Question 14
Does the person have frequent fluid-type bowel
movements?
Yes
No
Unsure / Do not know
Question 15
Does the person have mouth or teeth problems that
affect their eating?
Tick the ‘Yes’ box if any of the following apply:
The person’s teeth are loose, broken or missing;
The person’s lips, tongue, throat or gums are red
and inflamed or ulcerated;
The person has a malocclusion (upper and lower
teeth do not meet) and this affects their ability to
chew.
Yes
No
Unsure / Do not know
Question 16
Does the person suffer from frequent chest infections,
pneumonia, asthma or wheezing?
Tick the ‘Yes’ box if any of the following apply:
The person has had frequent chest infections or
pneumonia;
The person is usually ‘chesty’ or has difficulty
clearing phlegm;
The person has asthma or wheezes.
Yes
No
Unsure / Do not know
Question 17
Does the person cough, gag and choke or breathe
noisily during or after eating food, drinking, or taking
medication?
Tick the ‘Yes’ box if any of the following apply:
The person sometimes coughs or chokes during
or several minutes after eating, drinking or taking
medication;
The person’s breathing becomes noisy after
eating or drinking or while talking;
The person gags on eating, drinking or taking
medication.
Yes
No
Unsure / Do not know
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 26
Question 18
Does the person vomit or regurgitate on a regular
basis?
(Note: This question is not applicable to infants under
12 months of age)
Tick the ‘Yes’ box if either :
The person vomits or regurgitates (i.e. brings up)
food, drink or medication more than once per day
or on a regular basis;
The person takes anti-reflux medication;
The person clears their throat often or burps
often.
Not applicable
Yes
No
Unsure / Do not know
Question 19
Does the person drool or dribble saliva when resting,
eating or drinking?
Tick the ‘Yes’ box if either of the following apply:
The person drools or dribbles saliva at rest or
mealtimes;
The person’s clothes or protective napkins/bibs
frequently need changing because of drooling.
Yes
No
Unsure / Do not know
Question 20
Does food or drink fall out of the person’s mouth during
eating or drinking?
Tick the ‘Yes’ box if any of the following apply:
The person is unable to close their mouth and
this causes food, drink or medication to fall out of
their mouth;
The person cannot keep their head upright and
food, drink or medication falls out of their mouth;
The person’s tongue pushes food, drink or
medication out of their mouth;
The person’s mouth continuously needs to be
wiped or they need to wear a cloth to protect their
clothes during mealtime.
Note that this question does not relate to the person’s
manual dexterity or ability to place food in their mouth.
Yes
No
Unsure / Do not know
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 27
Question 21
If the person eats independently, do they overfill their
mouth or try to eat very quickly?
Tick the ‘Yes’ box if the person eats independently and
any of the following apply:
The person tries to cram or ‘stuff ’ their mouth
before attempting to chew or swallow;
The person tries to swallow too much food before
they have chewed it properly;
The person usually finishes all of their main meal
in less than five minutes.
Not applicable
Yes
No
Unsure / Do not know
Question 22
Does the person appear to eat without chewing?
(Note: This question does not apply to people on a
pureed diet)
Tick the ‘Yes’ box if any of the following apply:
The person sucks their food instead of chewing;
The food remains in the person ‘s mouth for a
long period of time before being swallowed;
The person swallows their food whole without
chewing.
Not applicable
Yes
No
Unsure / Do not know
Question 23
Does the person take a long time to eat their meals?
Tick the ‘Yes’ box if any of the following apply:
The person eats independently and they take
more than 30 minutes to eat meals;
The person is dependent on someone to feed
them and it takes a long time to feed them the
whole meal;
The person appears to tire as the meal
progresses and may not finish their meal.
Yes
No
Unsure / Do not know
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 28
Question 24
Does the person show distress during or after eating or
drinking?
Tick the ‘Yes’ box if any of the following apply:
The person appears distressed while they eat or
drink;
The person appears distressed immediately after
or shortly after eating or drinking;
Sometimes while distressed the person refuses
food or spits out food.
Yes
No
Unsure / Do not know
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 29
Part 3 – Summary of Results
Name of the person: Date:
Complete the table below for any questions answered with a ‘Yes’ or ‘Unsure/ Do not know’ response by describing the risk identified
or issue of concern in the ‘Comments’ column. Take the completed Risk Checklist and this summary to the appointment with the GP.
File the completed checklist and summary in the person’s Health and Wellbeing Plan – Part C.
Question
No.
Comments
Further Action Required
(GP to complete)
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 30
Question
No.
Comments
Further Action Required
(GP to complete)
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 31
Part 4 – Risk Checklist Verification
Note: Support workers completing this section are verifying that:
• the Risk Checklist has been completed
• all relevant referrals have been actioned
• the person’s My Safety Plan has been updated if required
• the Nutrition and Swallowing Risk Checklist is filed in the person’s My Health and Wellbeing Plan.
Name Position Signature Date
The person (if they are able)
Person completing the
Nutrition and Swallowing
Risk Checklist
Person/s assisting with
completion of the Nutrition
and Swallowing Risk
Checklist
Line Manager
- REMEMBER, IF ANYTHING CHANGES, RE-DO THE NUTRITION AND SWALLOWING RISK CHECKLIST -
32
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
The Mealtime Management Plan – Oral Only template has
been provided to assist the allied health professional
(AHP) and support workers to record the person’s
mealtime management requirements and preferences.
Where required, the GP or AHP should add or subtract
sections to suit the person’s support needs.
Name of person: CIS No.:
Preferred name: TRIM No.:
Address: Date of birth:
Phone No.:
Person responsible:
This is a new plan
Date
This is a review
Date
Mealtime Management Plan – Oral Only
Mealtime Management Plan prepared by
Name: Profession:
Contact details:
Name: Profession:
Contact details:
Name: Profession:
Contact details:
Insert a photograph
of the person
33
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
Allergies
Precautions
In RED CAPITAL LETTERS, list any food allergies here
Response
Strategies
PRN Medication
All PRN medication for allergy must be administered as per GP or
specialist recommendations
Medications
Refer to the person’s medication chart or Webster-pak® signing sheet for medication
preparation and timing.
Special support required to receive medication
Summary of important issues
34
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
Description: Eating Drinking
Consistency
1
Description Eating Drinking
Alertness
Comments regarding level of alertness at mealtimes
Amounts
Refer to dietetic
recommendations
Refer to dietetic
recommendations
Special diet
Examples:
Weight reduction
Weight maintenance
Phenylketonuria
Lactose free
Utensils /
equipment
(Insert photos if
appropriate)
1
http://www.speechpathologyaustralia.org.au/resources/terminology-for-modified-foods-and-fluids
35
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
Description Eating Drinking
Positioning
(Insert photos if
appropriate)
During Meals
After Meals
Assistance
required
(insert photos if
appropriate)
Likes
Dislikes
Religious and
cultural
preferences
Oral care
Refer to oral care plan = maintain oral hygiene at all times
Communication
This is how the
person
communicates
(Refer to
communication
profile)
Feeling full
Would like more to eat or drink
Needing help
Likes something
Dislikes something
Other
36
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
Behaviour
This is how the
person usually
behaves
Before meals
During meals
After meals
Other
Supervision
required during
mealtimes
While eating and drinking
To prevent grabbing food and fluids
To prevent sharing food with others
Preferences
Time taken to
eat meals
Breakfast
Lunch
Dinner
Snacks
Drinks
Other
Environment /
atmosphere
Noise level
Table setting
Position at the table
Companions
Lighting
Furniture Layout
Other
37
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
Preferences
Participation
Menu planning
Meal preparation
Eating out
Best atmosphere
Favourite meal
Favourite drink
Favourite venues
Support items to take
Photograph
This is how it looks to support the person to eat their meals in the best way possible.
Insert a photo(s) of the person to document:
safe and appropriate position for eating and drinking
equipment required, use of clothing protectors, utensils and aids.
Date photo taken: Photo taken by:
38
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
Review of Plan
Set Review Date Profession (AHP)
Signature
As needed review This plan will be reviewed following a problem being identified,
re-completion of the Nutrition and Swallowing Risk Checklist, and advice from the
person’s GP
Note: if the person appears to have difficulty with any support prescribed,
immediately contact the health professional responsible for the
development of this plan for advice.
Plan endorsement
The person (if they are able): Date:
Family/Guardian or person responsible: Date:
Profession: Date:
Name: Signature:
Profession: Date:
Name: Signature:
Profession: Date:
Name: Signature:
Line Manager:(position) Name:
Signature: Date:
39
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
A copy of the Mealtime Management Plan must be provided to any person(s) or
organisation(s) who provides support to the person during mealtimes.
Support provider Date provided Provided to (name)
Day placement
School / education centre
Family
Friends
Centre based respite
Holiday provider
Other – list below
Consent for sharing this information should be obtained from the person or
person responsible
40
Nutrition and Swallowing, Tools and templates, V1.3, June 2016
SUPPORT WORKER ENDORSEMENT
I have read and understood the Mealtime Management Plan and am able to implement it.
I have received practical training in mealtime management as per requirements in this plan.
I understand my duty of care regarding positioning, support and monitoring of risk for this
person.
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
A new page must be completed anytime the person’s Mealtime
Management Plan changes.
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 41
The Enteral Nutrition Plan – Nil by Mouth template has
been provided to assist the GP and or allied health
professional (AHP) to record the person’s enteral
nutrition requirements.
Note: Only an accredited practising dietitian (APD) can
develop and review a person’s enteral diet.
Where additional detail is required, or not needed, the
GP or AHP can alter the template to suit the person’s requirements.
Name of person: CIS No.:
Preferred name: TRIM No.:
Address: Date of birth:
Phone No.:
Person responsible:
This is a new plan
Date:
This is a review
Date:
Enteral Nutrition Plan – Nil by Mouth
Enteral Nutrition Plan prepared by:
Name: Profession:
Contact details:
Name: Profession:
Contact details:
Name: Profession:
Contact details:
Insert a photograph
of the person
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 42
Allergies:
Precautions
In RED CAPITAL LETTERS, list any food allergies here
Response
strategies
PRN medication
All PRN medication for allergy must be administered as per GP or
specialist recommendations
Medications:
Refer to the person’s medication chart or Webster-pak® signing sheet for medication
preparation and timing.
Special support required
to receive medication
Water amount given
between each medication
Enteral Nutrition
Type of diet:
Continuous / Intermittent/
Bolus
Equipment required
Delivery route
Formula
Rate / volume / breaks /
frequency
Total volume feed per day
Flush water
Environment
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 43
Enteral Nutrition
Alertness
Positioning for enteral
feeding – during and after
feeds
The person must be
upright or at least 30°for
30 minutes post enteral
feeds.
Risks
Likes
Dislikes
Oral care
Stoma care
Procedure if tube is
dislodged
Procedure if tube is
blocked
Safety
Use of gloves / hand
washing
Storage and expiry of
food
Food safety and hygiene
Cleaning and storage of
equipment
Other
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 44
Communication
This is how the person
communicates
(Please refer to the
person’s communication
profile for in-depth
information)
Likes something:
Dislikes something:
Something is wrong:
Other:
Behaviour
This is how the
person usually
behaves
Before a meal:
After a meal:
Other:
Preferences
Environment /
atmosphere
Noise level:
Table setting:
Position at the table:
Companions:
Lighting:
Furniture layout:
Other:
Participation
Meal preparation:
Eating out:
(where possible)
Favourite place:
Best atmosphere:
Best time of day:
Things to take:
Other:
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 45
Equipment and supply
Contact details
for food and
equipment
supply
Company:
Contact person:
Phone:
www:
email:
address:
Photograph
This is how it looks to support the person to eat their meals in the best way possible.
Insert a photo(s) of the person to document:
safe and appropriate position for tube feeding
equipment required, use of clothing protectors and aids.
Date photo taken: Photo taken by:
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 46
Review of plan
Set review: Date: Profession: (AHP)
Signature:
As needed review: This plan will be reviewed following
a problem being identified while following this plan
a new risk being identified through the Nutrition and Swallowing Risk Checklist
advice from the person’s GP/ allied health professional
Note: if the person appears to have difficulty with any support prescribed,
immediately contact the health professional responsible for the development
of this plan for advice.
Plan endorsement
The person (if they are able): Date:
Family/Guardian or person responsible: Date:
Profession: Date:
Name: Signature:
Profession: Date:
Name: Signature:
Profession: Date:
Name: Signature:
Line Manager:(position) Name:
Signature: Date:
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 47
A copy of the Enteral Nutrition Plan must be provided to any person(s) or
organisation(s) who provides support for the person to receive enteral nutrition.
Support provider: Date
provided:
Provided to (name):
Day placement
School / education centre
Family
Friends
Centre based respite
Holiday provider
Other – list below
Consent for sharing this information should be obtained from the person or
person responsible
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 48
Support Worker Endorsement
I have read and understood this Enteral Nutrition Plan and am able to implement it.
I have received practical training in mealtime management as per requirements in this plan.
I understand my duty of care regarding positioning, support and monitoring of risk for this
person.
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
A new page must be completed anytime the person’s Enteral Nutrition
Plan changes.
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 49
Name:
Time
Before feed
water flush (ml)
Formula
Volume of
formula (ml)
After feed water
flush (ml)
Medication
Progressive Total
Volume (ml)
Rate ml/h
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
24:00
Regime
provides:
Total input over 24hrs: Total output:
Balance over 24hrs:
Positive or negative balance:
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 50
The Enteral Nutrition Plan – Plus Oral Intake template
has been provided to assist the GP and or allied health
professional (AHP) to record the person’s enteral
nutrition and oral intake requirements.
Note: Only an accredited practising dietitian (APD) can
develop and review a person’s enteral diet.
Where additional detail is required, or not needed, the
GP or AHP can alter the template to suit the person’s requirements.
Name of person: CIS No.:
Preferred name: TRIM No.:
Address: Date of birth:
Phone No.:
Person responsible:
This is a new plan
Date:
This is a review
Date:
Enteral Nutrition Plan – Plus Oral Intake
Enteral Nutrition Plan prepared by:
Name: Profession:
Contact details:
Name: Profession:
Contact details:
Name: Profession:
Contact details:
Insert a photograph
of the person
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 51
Allergies:
Precautions:
In RED CAPITAL LETTERS, list any food allergies here:
Response
Strategies:
PRN medication
All PRN medication for allergy must be administered as per GP or
specialist recommendations
Medications:
Refer to the person’s medication chart or Webster-pak® signing sheet for medication
preparation and timing.
Special support required
to receive medication
Water amount given
between each medication
Enteral Nutrition
Type of diet:
Continuous / Intermittent/
Bolus
Equipment required
Delivery route
Formula
Rate / volume / breaks /
frequency
Total volume feed per day
Flush water
Environment
Alertness
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 52
Enteral Nutrition
Positioning for enteral
feeding – during and after
feeds
The person must be
upright or at least 30°for
30 minutes post enteral
feeds.
Risks
Likes
Dislikes
Stoma care
Procedure if tube is
dislodged
Procedures if tube is
blocked:
Safety
Use of gloves / hand
washing
Storage and expiry of
food
Food safety and hygiene
Cleaning and storage of
equipment
Other
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 53
Oral Intake
Description: Eating Drinking
Consistency
2
2
http://www.speechpathologyaustralia.org.au/resources/terminology-for-modified-foods-and-fluids
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 54
Description Eating Drinking
Alertness
Comments re level of alertness at mealtimes
Amounts
Refer to dietetic
recommendations
Refer to dietetic
recommendations
Special diet
Examples:
Weight reduction
Weight maintenance
Phenylketonuria
Lactose free
Utensils /
equipment
(Insert photos if
appropriate)
Positioning
(Insert photos if
appropriate)
For oral intake – during meal
After meal
Assistance
required
(insert photos if
appropriate)
Likes
Dislikes
Religious and
cultural
preferences
Oral care
Refer to oral care plan = maintain oral hygiene at all times
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 55
Communication
This is how the person
communicates:
(Please refer to the
person’s communication
profile for in-depth
information)
Likes something
Dislikes something
Something is wrong
Still hungry
Feeling full
Other
Behaviour
This is how the
person usually
behaves
Before meals
During meals
After meals
Other
Supervision
required during
mealtimes
While eating and drinking
To prevent grabbing food and fluids
To prevent sharing food with others
Time taken to
eat meals
Breakfast
Lunch
Dinner
Snacks
Drinks
Other
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 56
Preferences
Environment /
atmosphere
Noise level
Table setting
Position at the table
Companions
Lighting
Furniture Layout
Other
Participation
Menu planning
Meal preparation
Eating out
(where possible)
Favourite place
Favourite meal
Favourite drink
Best atmosphere
Support items to take
Equipment and supply
Contact details
for food and
equipment
supply
Company:
Contact person:
Phone:
www:
email:
address:
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 57
Photograph
This is how it looks to support the person to eat their meals in the best way possible.
Insert a photo(s) of the person to document:
safe and appropriate position for tube feeding and eating and drinking
equipment required, use of clothing protectors and aids.
Date photo taken: Photo taken by:
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 58
Review of plan
Set review: Date: Profession: (AHP)
Signature:
As needed review: This plan will be reviewed following
a problem being identified while following this plan
a new risk being identified through the Nutrition and Swallowing Risk Checklist
advice from the person’s GP/ allied health professional
Note: if the person appears to have difficulty with any support prescribed,
immediately contact the health professional responsible for the development
of this plan for advice.
Plan endorsement
The person (if they are able): Date:
Family/Guardian or person responsible: Date:
Profession: Date:
Name: Signature:
Profession: Date:
Name: Signature:
Profession: Date:
Name: Signature:
Line Manager:(position) Name:
Signature: Date:
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 59
A copy of the Enteral Nutrition Plan must be provided to any person(s) or
organisation(s) who provides support for the person to receive enteral nutrition.
Support provider: Date
provided:
Provided to (name):
Day placement
School / education centre
Family
Friends
Centre based respite
Holiday provider
Other – list below
Consent for sharing this information should be obtained from the person or
person responsible
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 60
Support worker endorsement
I have read and understood this Enteral Nutrition Plan and am able to implement it.
I have received practical training in mealtime management as per requirements in this plan.
I understand my duty of care regarding positioning, support and monitoring of risk for this
person.
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
Name: Signature: Date:
A new page must be completed anytime the person’s Enteral Nutrition
Plan changes.
Nutrition and Swallowing, Tools and templates, V1.3, June 2016 61
Name:
Time
Before feed
water flush (ml)
Formula
Volume of
formula (ml)
After feed water
flush (ml)
Medication
Progressive Total
Volume (ml)
Rate ml/h
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
24:00
Regime
provides:
Total input over 24hrs: Total output:
Balance over 24hrs:
Positive or negative balance:
62
Food diary
Name:__________________________ Date: ____________
Meal
Food and
Drinks
Amount
consumed
Time
Assisted
by:
Breakfast
Morning Tea
Lunch
Afternoon Tea
Dinner
Supper
63
Monitoring daily healthy eating and exercise
Name:__________________________ Date:________________
Mealtime
Record all foods and drinks daily
Food group checklist
Tick each item you consumed. Boxes indicate
the minimum serves per day each item should
be consumed. Refer to Australian Dietary
Guidelines for serving sizes.
Breakfast: Breads and cereals
Tick how many servings of breads and cereals
you ate (you should have 4)
Morning tea: Fruit
Tick how many servings of fruit you ate
(you should have 2)
Lunch: Vegetables
Tick how many servings of vegetables you ate
(you should have 5)
Afternoon tea: Dairy
Tick how many servings of dairy you ate
(you should have 2-3)
Dinner: Meat
Tick how many servings of meat and poultry,
fish, egg, legumes and nuts you ate (you should
have 2)
Treats: Treats
Tick how many servings of treat foods you had
e.g. sweet foods, fatty foods, alcohol, chocolate
Supper: Exercise
Did you do some exercise today? Yes No
What did you do?
How long did you exercise?
64
Menu planning checklist
This checklist is a tool that can be used to ensure everyone’s needs are being
met through menu planning. This is a general guide however, if a person has
specific needs, please refer to their My Eating and Drinking Profile / Mealtime
Management Plan or allied health practitioner recommendations.
Use the checklist to ensure menus are planned in a healthy way.
Considerations Yes No
When possible, has each person been included when making the menu?
Have each person’s special considerations been accounted for?
Is the menu appropriate for the season? (e.g. warmer meals in Winter)
Does the menu provide variety in all food groups?
Do the meals look good to eat?
Is the menu suitable for the available cooking equipment, time available
and capabilities of those cooking?
Are healthy choices available?
Unsaturated fats and oils such as olive oil are used instead of saturated
fats such as butter
No more than 2 out of 7 dinner meals are high in fat (i.e. only 2 dinners
have more than 20g of fat per 100g)
Red meat is included 3 times weekly
Vegetables are included – at least 4-5 serves daily
Fruit is included - 2 serves daily
Dairy is included - at least 2 serves daily
Breads and cereals are included - at least 2-3 serves daily
Wholegrain / wholemeal/ high fibre breads and cereals are included daily
High fibre cereals (over 8g of fibre per 100g serve) with low sugar content
(under 10g/100g) are chosen 4 times weekly.
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
65
Healthy food group shopping list
Shopping List Date: ______________
Breads
Flour
Cereals
Fruit
Vegetables
Meat
Eggs
Legumes
Dairy
Cheese
Milk
Yoghurt
Sugar
Oils
Other
66
Food safety kitchen equipment checklist
Items required
Disposable gloves – Non Latex, Non powdered
Food safety thermometer
Paper Towel
Blue or brightly coloured bandaids
Waterproof Apron
Bleach
Red chopping board – raw meat
Blue chopping board – raw fish
Yellow chopping board – cooked meats
Green chopping board – fruit & vegetables
White chopping board – breads & dairy
Food grade food storage containers
Disinfectant hand wash
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Disability Resource Hub Disclaimer (New South Wales)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document