ANFP Practice Standards: Documenting in the Medical Record

Last Updated November/December 2010

Professional Standards of Practice serve as the basis for quality dietetic practice for dietary managers. The standards that follow—updated in October 2010—provide guidelines for certified dietary managers to use when documenting food and fluid intake in the medical record.

Standard 1:

The certified dietary manager, certified food protection professional (CDM, CFPP) shall ensure that nutritional screening, food preferences, and food acceptance are accurately obtained, monitored, and recorded in the medical record in accordance with state/federal regulations and facility guidelines. The CDM shall ensure that food/fluid-related interventions are added to plans of care.

Criteria

1.1 Nutritional screenings are obtained from resident interviews and if not possible from surrogate decision makers or IDT (Interdisciplinary Team), in a timely manner that complies with regulatory agency guide-lines.

1.2 CDM, CFPPs use standardized forms for recording nutritional screening, such as the MDS (Minimum Data Set) and RAI (Resident Assessment Instrument).

1.3 Qualified dietary staff will receive training to obtain nutritional screening information

1.4 Food preferences/nutritional screening/fluid intake will be entered into the medical record by qualified staff according to state and federal regulations

1.5 Assist dietitian* in establishing and recording quality assurance indicators for nutrition care that are monitored, weaknesses identified and addressed.

1.6 All medical records are legal documents; entries in the medical record will be in black ink, dated, signed with full name and title, and never backdated or erased. Chart errors are corrected by a one-line strike out, initialed, dated, and labeled “error.”

1.7 In cases where facilities have an individual’s record maintained by computer, rather than hard copy, electronic signatures are acceptable. Following are guidelines for a computerized record system:

1.7.1 There is a written protocol, at the healthcare facility, describing the attestation policy in force at the facility.
1.7.2 The computer has built-in safeguards to minimize the possibility of fraud.
1.7.3 Each person responsible for an attestation has an individual identifier.
1.7.4 The date and time is recorded from the computer’s internal clock at the time of entry. An entry is not to be changed after it has been recorded.
1.7.5 The computer program controls what actions/ areas any individual can access or enter data, based on the individual’s personal identifier.

1.8 Progress notes reflect visual checks of amounts of client’s food intake and any abnormal food behavior.

1.9 Food intake information collected during meal rounds will be part of the nutritional screening document and shall be concise, timely, and reflective of the client’s current condition.

1.10 Visual food intake information, gathered by the CDM, dietitian, or IDT, is part of the nutritional screening and will include the following:

1) client does not consume 25 percent or more of food for two out of three days,
2) client does not consume all/almost all of fluids for two out of three days,
3) client does not have ability to chew, has mouth pain, or has signs and symptoms of a swallowing disorder,
4) client has difficulty using regular feeding utensils/ dinnerware.

1.11 Progress notes will also include a visual check of the dining environment (does the environment encourage residents to eat, provide a desirable social setting for meals, etc.).

1.12 A policy is in place stating which IDT (Interdisciplinary Team) member will ask the client interview questions about dietary preferences for dining, refusal of an ordered therapeutic diet, and desire for weight reduction; the policy will include how other family members or surrogate decision makers are to be included and how this information is communicated to the IDT.

1.13 Interventions are planned with the appropriate participation of health professionals to address family, staff, or resident’s food concerns.

Assessment

1.1 Copies of recent surveys indicate compliance with regulatory agency guidelines. Problem areas are noted and plans of correction are developed by the CDM, CFPP with dietitian consult.

1.2 Standardized forms are available and acknowledged by the administrator and dietitian.

1.3 Standardized parameters for anthropometric data, biochemical data, physical exam data, and client history data have been established by the facility and approved by the dietitian. (Examples of parameters can be found in the following document: Nutrition Diagnosis and Intervention: Standardized Language for the Nutrition Care Process by the American Dietetic Association.)

1.4 Records and files of staff training with objectives based on performance improvement, competency, and time frame, are completed and filed.

1.5 Copies of recent surveys indicate compliance with regulations regarding recording in the medical record.

1.6 Sufficient progress information exists to document change toward achieving care plan goals.

1.7 Medical records are audited for correctness of recording and appropriateness of the information either quarterly or per facility policy.

Standard 2:

The certified dietary manager, certified food protection professional (CDM, CFPP) shall ensure that procedures for documenting nutritional assessment are established according to regulatory agency guidelines or facility policies.

Criteria

1.1 The CDM, CFPP works with the dietitian to establish screening and nutritional assessment documentation procedures.

1.2 The nutrition assessment documentation procedure identifies who fills out what sections on the MDS, and how this information is communicated to the IDT.

1.3 CDM, CFPPs use standardized forms for recording as-sessment data such as the MDS (Minimum Data Set) and RAI (Resident Assessment Instrument).

1.4 All medical records are legal documents; entries in the medical record will be in black ink, dated, signed with full name and title, and never backdated or erased. Chart errors are corrected by a one-line strike out, initialed, dated, and labeled “error.”

1.5 In cases where facilities have an individual’s record maintained by computer, rather than hard copy, electronic signatures are acceptable. Following are guidelines for a computerized record system:

1.5.1 There is a written protocol, at the healthcare facility, describing the attestation policy in force at the facility.
1.5.2 The computer has built-in safeguards to minimize the possibility of fraud.
1.5.3 Each person responsible for an attestation has an individual identifier.
1.5.4 The date and time is recorded from the computer’s internal clock at the time of entry.
1.5.5 An entry is not to be changed after it has been recorded.
1.5.6 The computer program controls what actions/ areas any individual can access or enter data, based on the individual’s personal identifier.

1.6 CDM, CFPPs document nutritional screening data such as p/o intake, heights, weights, lab values, changes in diagnosis, oral health status, or other parameters assessed by the dietitian.

1.7 CDM, CFPPs will do visual meal rounds, and document actual dietary intake.

Assessment

1.1 Facility protocol for screening and nutritional assessment, is signed off with the dietitian, and is on file in the dietary department.

1.2 The nutrition assessment documentation procedure ensures clearly defined roles for the CDM and dietitian in screening all sections of MDS for nutrition related data, in documenting nutrition and swallowing data, and how this data is communicated to IDT and used in care planning.

1.3 Standardized parameters for anthropometric data, biochemical data, physical exam data, and client history data have been established by the facility and approved by the dietitian. (Examples of parameters can be found in the following document: Nutrition Diagnosis and Intervention: Standardized Language for the Nutrition Care Process by the American Dietetic Association.).

1.4 Standardized forms are available and acknowledged by appropriate staff per facility protocols.

1.5 Sufficient progress information exists to document all changes toward achieving care plan goals and rationale for those changes

Summing it Up

These guidelines offer help for CDM, CFPPs responsible for documenting food history, preferences, and intake. Refer to them as needed.

* Refers to Registered Dietitian (RD), Licensed Dietitian (LD), Certified Dietitian (CD).

By Susan Davis Allen, MS, RD, CHE
Allen is Director of Institutional Advancement at Southwest Wisconsin Technical College in Fennimore, WI. She serves as an advisor to the Certifying Board for Dietary Managers and has authored many publications for ANFP and other professional groups.