Meal Observation Form
Score (# of yes/number possible; do not include N/A)
SCORE
Person completing meal observation:
*
First Name
Last Name
Email of person completing meal observation:
*
example@example.com
Date of observation
*
-
Month
-
Day
Year
Date
ICF Location:
*
Park West
Johnstown
Apartment
*
A1
A2
A3
B1
B2
B3
C2
C3
Time of observation
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Employee Name working during meal:
*
First Name
Last Name
Employee Name working during meal:
First Name
Last Name
Employee Name working during meal:
First Name
Last Name
Initials of individuals home during meal:
MEAL OBSERVATION QUESTIONS?
YES
NO
N/A
Individuals seated per seating chart?
All staff and individuals washed hands before meal and between contact?
Appropriate condiments on table offered?
Everyone seated at table before food served?
Placemats used?
All proper adaptive equipment used?
All foods served within 15 min when removed from temperature control?
Accurate textures/thickened liquids served?
Accurate portion sizes served?
Full set of silverware (all 3 utensils)?
Pitchers used? (white=milk, black=other)
All food served at table using serving bowls, platters?
Accurate serving level followed (listed on corner of placemat)?
Was menu followed?
Substitutions offered appropriately?
Substitutions documented?
Items not passed between tables?
Swallowing strategies listed on placemat followed?
Any cross contaminated food disposed of?
Nobody left unattended while eating?
Leftovers correctly labelled and stored?
Timeline of meal followed? (ie Dinner 430-530p)
Any food dropped by individual replaced?
Staff seated at table during meal?
All staff have own place setting?
All staff role modeling appropriate meal skills?
Individuals participated in FSD- Serving food from platters/serving dishes for self or with assistance as outlined in their plans and were encouraged to pass serving dishes and scoop portions (unless otherwise noted)
MEAL OBSERVATION QUESTIONS?
YES
NO
N/A
Individuals seated per seating chart with appropriate social-distancing?
All staff and individuals washed hands before meal and between contact?
Everyone seated at table before food served?
Placemats used?
All proper adaptive equipment used?
All foods served within 15 min when removed from temperature control?
Accurate textures/thickened liquids served?
Accurate portion sizes served?
Full set of silverware (all 3 utensils)?
At least two drinks offered to each individual?
Was menu followed?
Substitutions offered appropriately?
Substitutions documented?
Items not passed between tables?
Swallowing strategies listed on placemat followed?
Any cross contaminated food disposed of?
Nobody left unattended while eating?
Leftovers correctly labelled and stored?
Timeline of meal followed? (ie Dinner 430-530p)
Any food dropped by individual replaced?
Staff feeding individual seated at table during meal?
All staff role modeling appropriate meal skills?
All areas sanitized before and after meal?
Individuals participated in FSD- passing serving dishes and serving own portions by self or with assistance as outlined in plan (unless otherwise noted)
Were there any disruptions displayed by individuals during meal that did not support a home like dining experience?
Instruction provided? Please detail below:
Comments:
Percentage (divide above and list below)
Please notify the case manager via email if you have questions, concerns, or compliments.
Submit
Should be Empty: