NFMNT Chapter 9 Document Nutritional Information in the Medical Record

1. Nutrition Fundamentals and Medical
Nutrition Therapy
Document Nutritional Information in
the Medical Record
Corresponds with
LEARNING PLAN 9
Copyright 2016 Association of Nutrition and Foodservice
Professionals

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. Nutrition Care Process (NCP)
 The first step - nutrition assessment - consists of five
areas
1. Food/Nutrition-related history
2. Anthropometric measurements
3. Biochemical data, medical tests, procedures
4. Nutrition-focused physical findings
5. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. CMS Regulations
 Begin with Resident Assessment Instrument (RAI)
 Three basic components of RAI
1. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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