Fluid Intake: Assessing Fluid Needs & Documenting Intake

Competency Area 1

Fluid Intake: Assessing Fluid Needs & Documenting Intake

Updated: January 2019

Overview: The certified dietary manager (CDM) is responsible for providing adequate hydration for their customers. This involves understanding the process of assessing fluids needs and documenting fluid intake as needed.

Supplemental Material: Access the Gap Analysis Tool to supplement your practices.

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Standard 1

The certified dietary manager (CDM) assesses customers’ daily fluid needs or assists the Registered Dietitian Nutritionist (RDN) in clinical duties related to fluid intake.

Criteria

Implement & Evaluate

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.

Hydration forms and checklists:
✓ Providers Web (for a fee)
✓ AND Nutrition Care Manual
✓ RD411.com

1.2 Client fluid needs are assessed based on an individualized basis and considering clinical status.

Estimating Daily Fluid Needs

For Average Adults: 30 mL/kg

For Adults with Infection or Draining Wounds: 35 mL/kg

For Adults with CHF or Renal Disease: 25 mL/kg

Note: 1 oz = 30 mL or cc

1.3 Hydration interventions are added to the plan of care and documented in the clients’ medical record.

Standard 2

The certified dietary manager (CDM) is responsible for providing adequate fluids to clients and documenting fluid intake as needed.

Criteria

Implement & Evaluate

2.1 The menu includes a predetermined amount of fluid to be provided for clients each day.

✓ Foodservice staff has a notification system for clients on fluid restriction or have additional fluid needs.

2.2 Daily fluid intake is recorded for new clients and those at risk for dehydration.

✓ Include all fluid intake including during and between meals.

2.3 Fluid intake is entered into the medical record by qualified staff according to state regulations.

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

✓ Policy includes role of interdisciplinary team (RDN, RN, Speech or Occupational Therapy and others)

2.5 For clients at risk of dehydration: assessment of hydration/dehydration is evaluated, interpreted, and documented in the client's medical record by the Registered Dietitian Nutritionist (RDN)

2.6 Qualified foodservice staff is trained on documenting fluid intake on standardized forms approved by the facility.

Competency Training:
✓ CDM trains staff on documenting fluid intake & other functions applicable to their job
✓ CDM documents competency training/in-service attendance and competency skill testing evaluation
✓ CDM keeps records in the department



Resources

Zikmund, Julie. Nutrition Fundamentals and Medical Nutrition Therapy. St. Charles, IL: Association of Nutrition & Foodservice Professionals, 2015.


Kristin Klinefelter, MS, RDN, LD has been in the dietetics field for 20 years, working in a variety of consulting and education capacities. She has been working with the University of North Dakota's Nutrition and Foodservice Training Program for ten years and served on the Certifying Board for Dietary Managers (CBDM) for six years.


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