NFMNT Chapter 9 Document Nutritional Information in the Medical Record

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


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


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


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 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



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



The Certified Dietary Manager may complete screening information

The Registered Dietitian Nutritionist is responsible for completing» Assessment» Diagnosis» Intervention» PES statement


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


SOAP Notes

Use the Subjective, Objective, Assessment, Plan approach to organize nutrition screening data


Brain Break

Using the SOAP example, what type of information are the results of lab tests for a client?

» Objective


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


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


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


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


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


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


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


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


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


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


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


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.


Education

NFMNT Chapter 9 Document Nutritional Information in the Medical Record