CENTRAL MINDANAO UNIVERSITY

COLLEGE OF HUMAN ECOLOGY

DEPARTMENT OF NUTRITION AND DIETETICS
CMU NUTRITION CLINIC

NUTRITION CARE PLAN

Patient/Client Name: _________________________________ Sex: ______ Age:______ Medical condition:_____________________

Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and

Goals Actions/Strategies Evaluation
1.) Anthropometry PES No. 1: Goal No. 1: For Goal No. 1: For Goal No. 1:
a. Term (value- 1.) To 1.) Food/Nutrient Delivery (ND) 1.) Anthropometry (AD)
interpretation) a. a.
b. Term (value- 2.) Nutrition Education (E) 2.) Biochemistry (BD)
interpretation) Goal No. 2 a. a.
c. Term (value- 1.) 3.) Nutrition Counseling (C) 3.) Nutrition-Focused PF (PD)
interpretation) a. a.
2.) Biochemistry 4.) Coordination of Nutrition Care 4.) Food/Nutrition-RH (FH)
a. Term (value, put ↑ if (RC) a.
high) a.
b. Term (value, put ↓ if For Goal No. 2:
low) For Goal No. 2: 1.) Anthropometry (AD)
c. Term (value, put ↕ if 1.) Food/Nutrient Delivery (ND) a.
normal) a. 2.) Biochemistry (BD)
3.) Nutrition-Focused PF 2.) Nutrition Education (E) a.
a. Term a. 3.) Nutrition-Focused PF (PD)
b. Term (value) 3.) Nutrition Counseling (C) a.
c. Term (value – a. 4.) Food/Nutrition-RH (FH)
interpretation) 4.) Coordination of Nutrition Care a.
4.) Food/Nutrition-RH (RC)
a. Term a.
b. Term (value)
c. Term (value-
interpretation)
5.) Client History
a. Term
b. Term
References:

Prepared by:

___________________________, SND
Student Nutritionist-Dietitian
Date: _________________

Checked by:

WILMAR JUN O. ELOPRE, RND

Supervising Dietitian/Instructor
Date: _________________

Other Instructions (remove these from the document when you submit an actual output):

1. Follow the format above. Things should be written in the same way as given above.
2. Only 1 nutrition diagnosis should be put per row.
3. Italicize your nutrition diagnosis.
4. Put N/A if no relevant data is available for that domain/area.
5. Should there be another nutrition diagnosis, do not hesitate to write it in the next row along with the corresponding data.
6. Our NCP must be evidence-based. So, if a goal or action/strategy warrants a literature citation, put it in the references section below the table (Arial Narrow,
size 10, in APA style).
7. Make an electronic version of your signature and sign your NCP above your name in the prepared by section before submission. I might tell you to revise your
NCP before I sign it as correct and finished.