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ANFP Practice Standards: Documenting Fluid Intake

CPE Accredited Provider - CDRApproved for 1 hr CE for CDM, CFPPs and 1 CPE hour (level 1) for RDs and DTRs.
Earn CE for this by purchasing a CE form in the Marketplace

Professional Standards of Practice serve as the basis for quality dietetic practice for dietary managers. The standard that follows updated April 2011, provides guidelines for dietary managers to document fluid intake.

Last Updated May 2011

Standard

The certified dietary manager, certified food protection professional (CDM, CFPP) shall ensure that clients maintain adequate hydration. The CDM, CFPP shall ensure that hydration interventions are added to the plan of care.

Criteria

1.1 Nutritional screenings including dehydration risk factors are obtained from clients and from medical record review in a timely manner that complies with regulatory agency guidelines.

1.2 Client fluid needs are determined upon initial screening and each subsequent care conference or significant change.

1.3 The Foodservice Department has a predetermined minimum amount of fluid to be served on each meal tray.

1.4 Qualified foodservice professional staff receives training to complete fluid estimation and documentation forms.

1.5 Fluid intake is recorded after meals and between meals for new clients, and those deemed at risk for dehydration. (See sample cc Conversion Sheet for Tallying Between-Meal Fluid Intake.)

1.6 Fluid intake will be entered into the medical record by qualified staff according to state regulations.

1.7 Facility has a hydration intervention policy and procedure in place for clients who are at risk for dehydration.

1.8 CDM, CFPPs use standardized forms approved by the facility for recording fluid intake. (See sample Beverage Estimation Visual and Food and Fluid Intake Tracking Form.)

1.9 Assessment of hydration/dehydration is evaluated, interpreted, and documented in the client's medical record by the dietitian.*

Summing It Up
Make sure your facility has an effective hydration policy in place. Understanding how to accurately document fluid intake is critical to the health and well being of your clients.

*Dietitian refers to one or more of the following credentials: Registered Dietitian (RD), Licensed Dietitian (LD), Certified Dietitian (CD)

Susan Davis Allen, MS, RD, CHE is the original author of this Practice Standard, first published in 2005. It was updated in April 2011 by Becky Rude, MS, RD, CDM, CFPP. Allen is an advisor to the Certifying Board for Dietary Managers. Rude serves as chair of that board. Both have authored many publications for ANFP and other professional groups.