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CHAPTER 10 | Document/Chart Nutrition Information in Health Records


plan is used by all IDT team members such as nursing, activity services, social services, therapy services, and nutrition services. Writing in the nutrition progress notes and the care plan is a joint effort of the CDM, CFPP; RDN; and NDTR. State regulations may vary as to how often the progress notes and care plans must be updated. Chapter 11 will discuss the care plan much more, but for now, the most important thing to understand that the CDM, CFPP should understand their Scope of Practice and know their facility policy regarding what information they are allowed to document upon. It may be that facility policy only allows the RDN/NDTR or MDS-RN to complete the progress note or care plan, so it is vital to know this information.


Chapter Summary


The CDM, CFPP should be acquainted with the necessary tools used in the nutrition services department so they can be productive in their workplace. These tools often include a therapeutic diet manual, diet office software or menu and client filing system, and meal tray cards. These tools will ensure that evidence-based processes are followed, accuracy is ensured, and client safety is protected. The health record is a tool that every clinical service in a healthcare facility will use, so it is essential to understand the components of documenting in the health record and how to always keep protected information safe according to HIPAA. Using standardized documentation of nutritional data is an essential method of practice for medical management as well as regulatory compliance. Nutrition professionals will typically use standardized charting methods and language consistent with the Nutrition Care Process. This method is the ADIME format and incorporation of PES statements. Documenting in the nutrition progress notes and the care plan is a joint effort of the CDM, CFPP; RDN; and NDTR. Again, the CDM, CFPP should always have a copy of their Scope of Practice available and refer to it and their facility policy regarding what information they are allowed to document upon.


Nutrition Fundamentals and Medical Nutrition Therapy


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