Nutrition Monitoring and Evaluation and Documentation 113


vegetables; dietary behaviors, including eating out and screen time; medications and supplements; PA


○ anthropometric measurements including, but not limited to, weight and BMI, WC, and body compo- sition (if available);


○ biochemical data, medical tests and procedures,


including, but not limited to, BG, endocrine, and lipid profiles; and


○ nutrition-focused physical findings including, but not limited to, affect, appetite, BP, body language, and heart rate (WM, Strong).


• Monitor energy intake and nutrient content and con- sider adjusting the calorie-reduction strategy (if necessary) by prescribing5


:


○ an eating plan with 1,200 to 1,500 kcal/d for women and 1,500 to 1,800 kcal/d for men (kcal are usually adjusted for the individual’s body weight);


○ an energy deficit of 500 to 750 kcal/d; or ○ one evidence-based eating patterns that


restricts


certain food types (such as high-carbohydrate, low-fiber foods, or high-fat foods) to create an energy deficit (WM, Strong).


• Monitor total energy needs and consider remeasuring resting metabolic rate (RMR) using indirect calo- rimetry or recalculating using the Mifflin-St Jeor equation or reapplying the new PA factor to RMR (WM, Consensus)5


Documentation of Nutrition Care


Documentation in the client’s medical record serves as a communication tool for members of the health care team. Concise, timely, accurate, and high-quality information provides evidence that


the individualized nutrition care


plan developed by the RDN is effective. The medical record also serves as a legal document of what was done and not


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