Diet Order Sheet

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Health Medical

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Sample Diet Order Reference Sheet Template DEFINITION: INDICATIONS: CONTRAINDICATIONS: CALORIE LEVEL: If required (see instructions) FOODS TO INCLUDE/EXCLUDE: Food Group Foods to Include Foods to Exclude Vegetables Fruits Grains Dairy Protein Foods Other References: Sample Regular Diet This diet is the standard diet for use in the hospital or in other healthcare facilities. It may also be called a ‘House Diet.’ Though standard portions are used, no foods are restricted on this diet. INDICATIONS: This diet is indicated for all patients not requiring texture and/or nutrient modification. CONTRAINDICATIONS: Any individual requiring additional restriction because of their particular medical condition. CALORIE LEVEL: Calories: 2000 – 2500 • Carbohydrate: 45 – 65% kcal; Protein: 15 – 20% kcal; Fat: 20 – 35% kcal FOODS TO INCLUDE/EXCLUDE: Foods to Include Foods to Exclude All foods are included None SAMPLE SERVING SIZES: Food Group Servings/Day Vegetables 4-6 servings Fruits 2-4 servings Grains 6-8 servings Dairy 3 servings Protein Foods 6-7 servings Fats & Oils 5-7 servings Calories Examples of 1 serving 1 cup of cooked or raw veggies; 2 cups of leafy greens 1 cup of cooked or raw fruit; 1 cup of 100% fruit juice; ½ cup dried fruit 1 slice of bread; ½ cup cooked rice, pasta, oatmeal; 1 ounce ready-toeat cereal 1 cup low-fat milk, yogurt, or fortified non-dairy milk; 1 ½ ounces of natural cheese; 2 ounces of processed cheese 1 ounce of chicken, beef, pork, fish; 1 egg; 1 Tbsp nut butter; ½ ounce of nuts; ¼ cup beans, peas, lentils 1 tsp butter, margarine, oil, mayo; 1 Tbsp salad dressing Discretionary Calories 125-150 240-300 480-640 270 330-385 315
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Running head: DIET ORDER SHEET

1

Diet Order Sheet
Name
Institution Affiliation

DIET ORDER SHEET

2
Full lipids diets

A full lipid diet involves lipids that are allowed on the clear diet of lipid which includes
small amounts of fiber and milk.
Indications: This diet is essential in the short term for transitioning steps in gastrointestinal
procedures of surgery
Contradiction: any specification that may be on demand by an individual.
The level of calories is 1400-1760
Foods to include and to exclude
Foods to include

Foods not to exclude

All food is included

None

Sample serving size
Food group

Serving/day

Example of 1 serving

Calories

Milk and its products

2-4 servings

1 cup of milkshakes,

250

1 cup frozen yogurt,
custard
vegetables

4-8 servings

1 cup of cooked

120-150

veggies; 2 cups of
leafy greens
Grains and bread

6-8 servings

One slice of bread; ½
cup of rice;1 ounce
ready to eat cereal

485- 640

DIET ORDER SHEET
Fats and oils

3
6-7 servings

Oil, mayo, margarine, 320
1tsp of salad dressing

Discretionary calories

200-400

Clear lipids
It contains plain gelatin, broth, and water and helps to maintain adequate hydration by
providing electrolytes.
Indications: This diet is essential in the short term use before tests, surgeries which require food
in the intestines.
Contradiction: any specification that may be on demand by an individual.
The level of calories is 1000-1100
Foods to include and to exclude
Food to include

Food to exclude

All food is included

None

Sample of serving diet
Food group

Service/ day

Example of 1 serving

Calories

Vegetables

4-8 servings

1 cup of strained
tomato; 1 cup of
vegetable juice

150

DIET ORDER SHEET

4

Grains

4-6 servings

1 ounce ready to eat
cereal; seeds or nuts

Water

8-12 servings

2 cups of plain water,
2 cups of flavored or
carbonated water

Fruits

4-6 servings

1 cup of fruit juice
without pulp; 1 cup
of flavored beverages

450-650

230-300

Blenderized-Straw diet
The diet contains lipids and foods which have been thinned of the process to be taken
using straw, spoon, and cups.
Indications: It is essential for the individual who can not swallow or chew any solid food such as
those who have mouth pain, face surgery among others.
Contradiction: any specification that may be on demand by an individual.
The level of calories is 1200-1410
Foods to include and to exclude
Foods to include

Foods to exclude

All foods to be included

None

Sample for serving
Food group

Service/ day

Example of 1 serving

Calories

Vegetables

4-6 servings

Canned vegetables
without skins or
seeds

120-150

Grains

3-7 servings

½ cup of rice, pasta
or the noodles

450-640

DIET ORDER SHEET

5

Fats and oil

4-8 servings

Melted butter or
margarine; salad
dressing

320

Fruits

4-6 servings

Canned vegetables
that do not have skins
or seed

230-300

Post-Surgical diet
These are the types of diet adding calories as well as nutrients for an individual to recover
quickly
Indications: It is essential for the individual since it enables a reduction in the risk of infection as
well as increasing the speed of healing.
Contradiction: any specification that may be on demand by an individual.
The level of calories is 500-695

Foods to include

Foods to exclude

All foods

Lactose-free

Sample of serving food
Food group

Service/day

Example of 1 serving

Calories

Milk and its products

8-12 servings

1 cup of yogurt; kefir

270

Fruits

3-6 servings

Blueberies;
strawberies;
pomegranates

280

Vegetables

3-6 servings

Cabbage; brussels
sprouts

145

DIET ORDER SHEET

6
High Ostomy Output

The diet contains lipids and foods as well as fluids for absorbing enough nutrition in the
body
Indications: It is essential for the individual to control the stool output.
Contradiction: any specification that may be on demand by an individual.
The level of calories is 1000-1135

Food to include

Food to exclude

All foods to be included

Honey; beverages having caffeine

Sample for serving
Food groups

Servings/ day

Example of 1 serving

Calories

Grains

5-6 servings

460-640

Dairy

Three servings

One slice of bread; ½
cup cooked rice,
pasta, oatmeal; 1ounce ready-to-eat
cereal
1 ½ ounces of natural
cheese; 2 ounces of
processed cheese

Fruits

3 servings

Bananas

230

265

DIET ORDER SHEET

7
Cardiac diet

The diet contains all food groups as well as fluids to receive enough nutrition and a lower
level of calories
Indications: It is essential to improve the level of blood pressure and cholesterol.
Contradiction: any specification that may be on demand by an individual
Foods to be included and excluded
Foods to be included

Foods not to be excluded

All groups of food to be included

Level of calories is 1200-1345

Food groups

Service/ day

Example of 1 service

Calories

Fruits

3 services

Grapes, apples
bananas, blueberries

203-300

Nuts

Four services

400-650

Dairy

Three services

Unsalted sunflower
seeds; cashews
unsalted, walnuts
unsalted.
Fat-free cheese; a
lower fat yogurt;...


Anonymous
Excellent resource! Really helped me get the gist of things.

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