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Nutrition Fundamentals and Medical Nutrition Therapy
Document Nutritional Information in the Medical Record
Corresponds with LEARNING PLAN 9Copyright 2016 Association of Nutrition and Foodservice Professionals
9
Objectives
Explain the uses of common documents, including a diet manual, medical record, and an MDS form
Chart in medical records using appropriate forms and formats
Translate commonly used abbreviations into medical terms
Enter and retrieve data using a computer
Describe the impact of HIPAA regulations on medical documentation
Use current nutrition forms
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Documentation is Essential
Helps focus details, implement a plan of care, track changes in nutritional status
Communication tool for interdisciplinary healthcare team
Required by government agencies
Requirement for reimbursement for services
A legal record
Affirmation of quality standards
Resource in monitoring quality of services
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Standardized Documents
Diet Manual» Specifies therapeutic diets and their application» Reference book and communication tool between MD and
nutrition services department» Should be readily available to all caregivers» Determines what information must be relayed in nutrition
education» CDM works with the RD and IDT to identify the standard diet
manual for diet planning
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Standardized Documents
Medical record (Medical chart)» Formal, legal account of a client’s health and disease» Paper, electronic (EHR) or a combination of both» POMR – Problem Oriented Medical Record
- Collection of data- Problem list- Plans for addressing each problem/progress notes- Evaluation summary including plans for follow-up or referral
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Brain Break
How are mistakes in the medical record handled?
» Mistakes are always lined out (e.g. lined out); they are never deleted or erased
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Nutrition Care Process (NCP)
Developed by Academy of Nutrition and Dietetics (Academy)
Five steps known as ADIME» Nutrition Assessment (begins after nutrition screening data
indicates client may benefit from nutrition care)» Nutrition Diagnosis» Nutrition Intervention» Monitoring» Evaluation
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Nutrition Care Process (NCP)
The first step - nutrition assessment - consists of five areas1. Food/Nutrition-related history2. Anthropometric measurements3. Biochemical data, medical tests, procedures4. Nutrition-focused physical findings5. Client history
The Certified Dietary Manager can collect and document information from these five areas
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Nutrition Care Process (NCP)
The Certified Dietary Manager may complete screening information
The Registered Dietitian Nutritionist is responsible for completing» Assessment» Diagnosis» Intervention» PES statement
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
SOAP Notes
Subjective» Data from the client’s point of view
Objective» Data acquired by inspection, examination, laboratory tests, and
X-rays
Assessment» Analysis based on the subjective and objective data
Plan» Recommended actions of the caregivers to further information,
therapy, education, or counseling
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
SOAP Notes
Use the Subjective, Objective, Assessment, Plan approach to organize nutrition screening data
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Brain Break
Using the SOAP example, what type of information are the results of lab tests for a client?
» Objective
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Charting Standards
Adhere to your facility policies
Sign with your credentials
Medical record is a legal document that will be read by many people, including the client
Review documentation guidelines in Figures 7.2 and 7.3
Use abbreviations only when they are accepted and approved at your facility» Refer to Figure 7.4
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Meal Related Documents
Diet Order» Is prescribed by the physician for an individual client» Follow policy jointly approved by nursing and nutrition
services to communicate and document diet order transmission
» Transmitted to dietary services; recorded in nutrition services records
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Federal Regulations for Nursing Facilities Regulated by the Centers for Medicare & Medicaid
Services (CMS)
Regulations address quality of care
Applicable for long-term care facilities and hospital swing beds
CMS requires certain documentation in a standardized format to be eligible for reimbursement for services
Stringent timelines apply to documentation requirements
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Brain Break
Nutrition services keeps internal records in their department on food preferences and diet related guidelines for individual clients. What else is required to meet legal guidelines?
» Documenting preferences and diet changes in the medical record, electronic or otherwise
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
CMS Regulations
Begin with Resident Assessment Instrument (RAI)
Three basic components of RAI1. Minimum Data Set (MDS)2. Care Area Assessment (CAA)3. RAI utilization Guidelines
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
MDS 3.0
Standardized reporting form to do an assessment of each resident, updated in 2010
Data gathering process that actively engages the client
Interdisciplinary care tool
Full assessment – upon admission and annually
Quarterly assessment – completed every three months
RD, DTR, or CDM, CFPP completes Section K» Responses are coded for use in the CAA process
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
MDS 3.0 – Section K
Intent is to prevent malnutrition, dehydration, and ensure the appropriate use of feeding tubes
Role of CDM in completing Section K» Ensure accurate information» Communicate with RDN and IDT» Follow up on recommendations by team» Participate in the RAI process
Note: On CMS forms, “cc” is the standard unit of measure for fluids
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Brain Break
A new client has just been admitted. How many days do you and the IDT team have to complete the RAI?
» 14 days
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
CAA Process and Care Planning
CAA process is decision making process
Review coded responses from MDS» 20 areas to address» CAT – Care Area Trigger » Review CAT using ‘CAT’ logic
Complete CAA using critical thinking skills and professional or clinical practice guidelines
Provides additional information to help develop the care plan if warranted
RAI and CAAs must be completed within 14 days of admission
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Utilization Guidelines
Detailed instructions when and how to use the RAI
Definition of ‘Significant Change’» Major change in the client’s status» Has an impact on more than one area of client’s health» Requires interdisciplinary review or revision
Care plan» Interventions that are individualized and appropriate for a particular
client» Care Planning Decision column must be completed within seven days
(7) of completing the RAI
Specific guidelines for readmission, or return from hospital stay
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
HIPAA
Health Insurance Portability and Accountability Act» Initiated in 2003
Patient privacy and medical information security» Every employee of a healthcare facility must adhere to an
established policy addressing privacy
Guidelines for electronic transfer of health information
Certified Dietary Manager is responsible to ensure compliance with HIPAA in their department
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9
Brain Break
What is the first step in developing a HIPAA plan for nutrition services?
» Looks for places where security of information is vulnerable such as department records, computer screens, tray cards with names, etc.
Nutrition Fundamentals and Medical Nutrition Therapy • Document Nutritional Information in the Medical Record • Learning Plan 9