Enteral Nutrition Documentation
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1
2
3Patient’s Name:
Date of Birth:
Medicaid ID #
Medical Diagnoses:
Method of feeds:
oral
NG
NJ-tube
G tube
GJ tube
(need to qualify oral feeds)
Is patient unable to reach or maintain weight and
Yes
th
height at the 10
percentile for age and sex without
Please provide growth chart
supplemental feeding?
No
Does patient have a disease or dysfunction of the
Yes
digestive tract, including dysphagia, which causes
Describe:
nutritional deficiency with insufficient nutrients to
maintain body weight by impaired delivery of
nutrients to the small bowel?
No
Formula Name:
Total Volume for 30 days:
HCPC Code: ( on back)
Amount required to meet 100% of daily estimated
needs for one day, total Kcal/day______________
Anticipated length of time needed: _____months
Method of Administration:
*Must document reason of necessity for pump.
Check all that apply (attach medical/clinical documentation)
Syringe
Severe diarrhea
Gravity
Dumping syndrome
Pump* type:_________________________
Reflux
Describe how feeds are administered:
Aspiration
Continuous
Blood glucose fluctuations
Intermittent
Nissen
Bolus
Jejunal feeds
ombination
___________________
(explain)
Ventilated and/or trached
Feeding difficulties (oral aversions)
_______________________________________
Date: _______________
Time: _______________
signature
Statement of Medical Necessity:
__________________________________MD/LIP Contact #:_____________Date: ______________
Enteral Nutrition Documentation
Jan 09
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