SUPPLEMENTAL MATERIAL CHAPTER 9 QUESTION
1. A client’s diet order would typically be listed what section of the medical record?
2. Explain why Yuki could be having protein-calorie malnutrition despite being ordered a high-protein, high calorie diet.
3. Jose has not been eating much of his meals, and his weight is decreasing undesirably. He mentions he isn’t eating as much because the food tastes bland. What can be done to help Jose?
4. A client is on a liberalized regular diet. Pumpkin pie is served to her during lunch. She has diabetes and has not been eating well for a few weeks. The client enjoys the pie; however, her husband feels she should not get dessert because of her diagnosis of diabetes. What should the CDM, CFPP do?
ANSWER
A diet order would most likely be included in the medical order section.
Yuki may be experiencing poor appetite or other barriers to consuming the food he is provided. Observing his diet tolerance/intake would be prudent to determine next steps.
Jose’s diet should be examined for ways to liberalize the food in ways he may enjoy more. His unintentional weight loss is of higher priority than, for instance, the sodium content of the meals.
No changes are needed because the client enjoys and wants the pie. Person-centered care means that each person makes decisions on their preferences and wishes (not the family’s wishes). However, this is a good opportunity to educate the client’s husband on the benefits of a liberalized diet in clients who are not eating well, and help him understand why and how it is OK for their loved one to have sweetened foods and beverages .
QUESTION
CHAPTER 10 ANSWER
1. The CDM, CFPP is visiting a newly-admitted client with dementia. The client has a visitor who is a close friend of the family. The visitor asks what type of diet the client is on because she wants to bring some food in for her. She also wants to know if the client is going home soon. What should the client’s visitor be told?
HIPAA dictates that client information and health- related data will be kept secure. All personal and medical information are confidential, this includes diet order and discharge plans. The CDM, CFPP must politely decline to give information to this visitor due to HIPAA guidelines. It’s good practice to alert the client’s nurse so that they can be aware of the situation and communicate this visitor’s questions with the family as appropriate.
2. The CDM, CFPP notices in the health record that a client’s blood sugar is high. What type of data is this?
3. Rewrite this statement using appropriate language and phrasing to enter in the EHR: The client complained that their lunch was cold. The food was cold because lunch was late due to call-ins this morning. FNS made a new tray for the client.
4. What should the CDM, CFPP remember when documenting anything in the client health record?
This is Objective data. Objective data is data that is acquired by inspection, examination, from the laboratory, and radiologic tests.
The client stated their food was cold today. Nursing notified FNS and a new tray was made and brought directly from the kitchen. The client was pleased with her meal at that time.
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Remember to always keep protected health information safe according to HIPAA regulations. If something is not documented, it is presumed it did not occur.
Nutrition Fundamentals and Medical Nutrition Therapy
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