Subjective Global Assessment Rating Form at a glance
What it is: The Subjective Global Assessment Rating Form has a Patient Name, ID # and Date, and a Baseline Weight and Current Weight.
A filled-in Subjective Global Assessment Rating Form example: a dietitian records a weight loss
How to fill out Subjective Global Assessment Rating Form, box by box
Patient and weight
Enter the Patient Name, ID # and Date, then the Baseline Weight (Dry weight from 6 months ago) and the Current Weight (Dry weight today).
Enter the Actual Wt loss/past 6 mo. and the % wt loss (actual loss from baseline/last SGA).
For Wt change over past two weeks, mark No change, Increase or Decrease, and enter the RATING.
Dietary intake
Under DIETARY INTAKE, mark No change (Adequate) or No change (Inadequate), or enter the Change: Sub optimal Intake, Protein, Kcal, Duration, Full Liquid, Hypocaloric Liquid or Starvation, with the RATING entered.
Gastrointestinal symptoms
Under GASTROINTESTINAL SYMPTOMS, enter the Frequency (Never, daily, 2-3 times/wk, 1-2 times/wk, > 2 weeks, < 2 weeks) and the Duration for None, Anorexia, Nausea, Vomiting or Diarrhea, with the RATING entered.
Functional capacity
Under FUNCTIONAL CAPACITY, enter the Description and the Duration: No Dysfunction, Change in Function, Difficulty with ambulation, Difficulty with activity (patient specific “normal”), Light activity, Bed/chair ridden with little or no activity or Improvement in function, with the RATING entered.
Diagnosis and co-morbidities
Under DIAGNOSIS/CO-MORBIDITIES RELATED TO NUTRITIONAL NEEDS, enter the Primary diagnosis and the Comorbidities, mark Normal requirements, Increased requirements or Decreased requirements, mark Acute Metabolic Stress as None, Low, Moderate or High, and enter the RATING.
Physical exam and overall rating
Under PHYSICAL EXAM, mark Loss of subcutaneous fat (Some areas or All areas), Muscle wasting (Some areas or All areas) and Edema (related to undernutrition/use to evaluate weight change), with the RATING entered.
For the OVERALL RATING, mark 6-7=Very Mild risk to well nourished, 3-4-5=Mild/Moderate; No clear sign of normal status or severe malnutrition, or 1-2=Severely Malnourished.
Fat and Muscle Store Assessment
On the Fat and Muscle Store Assessment page, enter the Date, Patient Name, SGA Score and Notes/Comments.
More rules for Subjective Global Assessment Rating Form
On the Fat and Muscle Store Assessment page, Edema (green) should be assessed at the ankle.
In mobility-restricted patients the edema may be visible around the eye or at the sacrum.
Sources
[1] Subjective Global Assessment Rating Form (Reviewed: 04-2012) (the served file; no issuer file found) (the Official source link on this page).