2.6 Documentation & Implementation

What must be documented in a patient medical record during the nutrition care process?

Every step of the nutrition care process must be documented in the medical record

What characteristics should medical record documentation entries possess?

Entries should cover important details and be easy to read and quickly understood by all members of the healthcare team

What basic information should be included in nutrition documentation entries?

Date and time

What are the two most common documentation formats used in clinical nutrition?

ADIME and SOAP

What does the letter A stand for in the ADIME documentation format?

Assessment

What information is included in the Assessment section of an ADIME note?

Anthropometric measurements

What does the letter D stand for in the ADIME documentation format?

Diagnosis

What is documented in the Diagnosis section of an ADIME note?

The specific nutrition problem requiring intervention written as a PES statement

What does the letter I stand for in the ADIME documentation format?

Intervention

What is documented in the Intervention section of an ADIME note?

Treatment goals

What do the letters M and E stand for in the ADIME documentation format?

Monitoring and Evaluation

How are Monitoring and Evaluation handled in ADIME documentation?

Monitoring and Evaluation are two steps usually combined together to record patient progress

What does the letter S stand for in the SOAP documentation format?

Subjective

What information is documented in the Subjective section of a SOAP note?

Information obtained in an interview with the patient or caregiver including chief medical problem and relevant symptoms

What does the letter O stand for in the SOAP documentation format?

Objective

What information is documented in the Objective section of a SOAP note?

Nutrition screening or assessment data such as anthropometric measurements

What does the letter A stand for in the SOAP documentation format?

Assessment

What information is documented in the Assessment section of a SOAP note?

A brief evaluation of the subjective and objective data and a concise nutrition diagnosis

What does the letter P stand for in the SOAP documentation format?

Plan

What information is documented in the Plan section of a SOAP note?

Recommendations to solve the problem including nutrition prescription

What is an Electronic Medical Record or EMR?

A digital version of paper charts used by a healthcare organization to document patient care within its network

What types of data are tracked over time in an EMR?

Vaccine records

How accessible is an EMR outside of its immediate practice network?

EMRs are typically confined within a specific healthcare system network and are not easily accessible outside that immediate practice

What is an Electronic Health Record or EHR?

An information system containing all health information for an individual built to go beyond standard clinical data and shareable across providers nationwide

How does an EHR differ from an EMR regarding data sharing?

An EHR moves with the patient and shares information across different healthcare providers

What is a Personal Health Record or PHR?

An electronic health information system maintained directly by the individual patient

What platform types can be used for a Personal Health Record?

Web based

What sources of information can feed into a Personal Health Record?

Clinicians

What is a care plan in clinical nutrition management?

A documented roadmap in the medical chart outlining the nutrition interventions to be implemented

How do the four components of the Nutrition Care Process relate to care plan quality?

Assessment

What are the four basic steps of implementing a patient care plan?

Counseling and training patients

Who should be actively involved during patient counseling and training?

The patient and their family or caregiver

What topics may be covered during patient nutrition training prior to discharge?

Therapeutic diet education

What format is used when writing care plans in patient medical records?

The ADIME format representing assessment

What healthcare professionals typically make up an interdisciplinary team or IDT?

Doctors

What two forms of communication must be used when sharing a care plan with an IDT?

Both verbal communication and written communication

Where does verbal communication among interdisciplinary team members usually take place?

During daily patient rounds or regularly scheduled care conferences

What is the main purpose of daily patient rounds or care conferences?

To discuss the patient plan of care and interventions in place and address additional problems that arise

Where do patient care conferences commonly occur?

Frequently in long term care facilities where the team meets with the resident and family

Why is written communication in the medical record essential following IDT meetings?

To document the plan

When does patient discharge planning begin in a healthcare facility?

Discharge planning begins as soon as the patient is admitted to the facility

How long does the care planning process continue for a hospitalized patient?

Until the patient is safely discharged from the facility

What discharge information regarding therapeutic diets should be provided to the patient?

The specific type of diet to follow along with written nutrition education materials

What discharge instructions are needed for patients on texture modified diets?

Verbal and written instructions detailing allowed and restricted foods for the ordered consistency

Why should specific oral nutrition supplement recommendations be written in the discharge plan?

Because insurance companies may cover the cost if documented as a medical need

What training must be completed before a patient is discharged on tube feeding or parenteral nutrition?

Assuring the patient and family are knowledgeable on proper scheduling

What community or outpatient follow up referrals may be recommended at discharge?

Community programs like Meals on Wheels or outpatient nutrition counseling for ongoing education