CHAPTER 10 | Document/Chart Nutrition Information in Health Records Professional Assessment


The third type of information in a progress note is the assessment of the information gathered. This is the healthcare professional’s informed opinion or judgment about the information gathered and documented in their note thus far. An assessment is the nutrition- related evidence-based clinical findings concluded from the data. RDNs and DTRs have in their Scope of Practice to assess and draw conclusions from nutrition-related clinical findings.


Plan of Action


The last portion of a clinical progress note is the plan of action. It answers the question of what will be done with all the information documented in the progress note. Examples of items in the plan of action include, but are not limited to, changes to current medical nutrition therapy; additions to current diet therapy including supplements, fortified foods, larger portions, etc.; goals for oral intake; goals for weight; referrals to other healthcare providers for specific reasons; plans for future monitoring by nutrition personnel; intent for care planning; etc.


Signature


Clinical progress notes always conclude with a signature of a legal name with credentials and a date. This can be done electronically when working in an EHR. Keep in mind that if something is not documented, it has legally not happened according to regulatory standards. Table 10.1 lists some standard rules for keeping good client records.


Abbreviations are used by healthcare professionals as shortcuts for medical and clinical terms in health records. See Chapter 12 for a list of medical abbreviations that are commonly used. Accepted standards for abbreviations may vary slightly, so make sure to obtain a facility’s approved list of abbreviations for reference when charting. It is also important to remember that the health record is a legal document. Maintain professionalism; do not criticize the facility, the client, or others. The CDM, CFPP should always work within their Scope of Practice. The following phrases show corrected documentation methods:


Clinical progress notes must conclude with a legal signature and date, as documentation is essential for compliance and accountability.


Glossary


Progress Note A notation in the health record by a health professional


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Nutrition Fundamentals and Medical Nutrition Therapy


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