RM. 12.8.

b
RSUD H. HANAFIE MUARA BUNGO
Jl. Teuku Umar No. 88 Rimbo Tengah
Telp. (0747) 21314 – 21315
Fax. (0747) 323494
No. Rekam Medis :...................................
Nama Lengkap :...................................
Tanggal Lahir :...................................
Jenis Kelamin :...................................

FORMULIR SKRINING LANJUT

DIAGNOSIS MEDIS :

BB : Kg TB : Cm IMT : Kg/m²
TINGGI LUTUT : Kg TB estimasi : Cm LILA : Cm

Parameter
1. Skor IMT SKOR

o IMT > 23 =0 ( )
o IMT 18,5-23 =1
o IMT < 18,5 =2

2. Skor kehilangan BB yang tidak direncanakan 3-6 bulan terakhir

o BB hilang < 5% =0 ( )
o BB hilang .5 – 10% =1
o BB hilang > 10% =2

3. Skor efek penyakit akut

o Ada asupan nutrisi > 5 hari =0 ( )

o Tidak ada asupan nutrisi > hari =1

Jumlah skor keseluruhan:

Hasil:2
0 : beresiko rendah ; ulang skrining setiap 7 hari
1 : resiko menengah ; monitoring asupan selama 3 hari, jika tidak ada peningkatan. Lanjutkan
pengkajian dan ulangi skrining setiap 7 hari
>2 berisiko tinggi; bekerja dengan Tim Dukungan Gizi/Panitia Asuhan Nutrisi

Upayakan peningkatan asupan gizi dengan memberikan makanan sesuai dengan daya terima
Monitoring asupan makanan setiap hari. Ulangi skrining setiap 7 hari

Hari/Tanggal:

Tanda tangan Ahli Gizi

( )
 RM. 12.8.c
FORMULIR ASUHAN GIZI

NRM :
NAMA :
J. KELAMIN :
TGL. LAHIR :

Tanggal :

Diagnosa Medis :
ASSESMENT GIZI
ANTROPOMETRI
BB : Kg Lingkar Lengan Atas : Cm
TB : Cm Tinggi Lutut : Cm
IMT : Kg/m² BB/TB : SD
BIOKIMIA

FISIK / KLINIS

RIWAYAT GIZI
Alergi Makan:
Ya Tidak Ya Tidak
Telur Udang
Susu sapi/olahannya Ikan
Kacang Kedele/Kc. Tanah Almond/Hazzenut
Gluten/Gandum

Pola Makan:

Data riwayat personal

 RM. 12.8.d
DIAGNOSA GIZI

1. Domain Asupan

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

2. Domain Klinis

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

3. Domain Prilaku

.........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

INTERVENSI GIZI

1. Tujuan Diet

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

2. Syarat Diet

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................
 PERHITUNGAN KEBUTUHAN GIZI

IMPLEMENTASI DIET

Jenis Diet :........................................ Bentuk Makanan :........................................

Frekuensi :......................................... Cara Pemberian :........................................

MONITORING DAN EVALUASI

Tanda tangan Ahli Gizi

( )
 Contoh Formulir Hidangan Sehari (Recall 24 Jam) Sebelum Sakit/Sebelum Dirawat

Makan Pagi Banyak Selingan Pagi Banyak

Gr URT gr URT

Makan Siang Banyak Selingan Siang Banyak

Gr URT gr URT

Makan Malam Banyak Selingan Malam Banyak

Gr URT gr URT

Kal Prot Lemak CHO Ca Fe Vit A Vit B Vit C

gr Gr gr gr gr SI mg mg
Rata-Rata
Sehari
% RDA
Sikap pasien terhadap diet

Anjuran untuk memperbaiki kebiasaan makanan/menjalankan diet

Tanggal Dietisien Tanda Tangan

Keterangan: Untuk pasien dengan diet khusus RDA diisi dengan kebutuhan dietnya.