PES Statement

Outcome indicator:

Target:

Reassessment date:

Plan and Follow-Up

Focus	Documentation
Nutrition diagnosis	Record PES statement, nutrition priority, evidence, and confidence in diagnosis. Problem: Etiology: Signs / symptoms:
Intervention	Document nutrition prescription, counseling strategy, resources, barriers, and patient agreement. Nutrition intervention: Barriers / supports: Patient agreement:
Monitoring	Set symptoms, intake, labs, anthropometrics, adherence, and follow-up interval. Monitoring indicators: Adherence / response: Follow-up:

Focus

Documentation

Nutrition diagnosis

Record PES statement, nutrition priority, evidence, and confidence in diagnosis.

Problem:

Etiology:

Signs / symptoms:

Intervention

Document nutrition prescription, counseling strategy, resources, barriers, and patient agreement.

Nutrition intervention:

Barriers / supports:

Patient agreement:

Monitoring

Set symptoms, intake, labs, anthropometrics, adherence, and follow-up interval.

Monitoring indicators:

Adherence / response:

Follow-up: