1. Ensure Policies and Procedures are in Place: The CDM, CFPP participates in the nutrition care process and collaborates with the dietitian to establish nutritional screening and assessment documentation policies and procedures. The policies state which qualified interdisciplinary team member will ask client interview questions regarding nutritional status, the care planning process, and how this information is communicated to the interdisciplinary team.
2. Complete Training and Maintain Your Credentials: CDM, CFPPs receive training on navigating the electronic medical records and how to obtain nutritional screening information. Records of staff training are filed within the facility. The CDM, CFPP maintains required credentials and continuing education within the facility.
3. Use Standardized Forms: CDM, CFPPs document using standardized forms such as components of the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), Care Area Assessment (CAA), and care plan. Standardized parameters for anthropometric, biochemical, physical exam, and client history data have been established by the facility and acknowledged by the CDM, CFPP and the dietitian.
4. Interview the Client: Nutritional screening data is obtained from client interviews in a timely manner that complies with your facility policy and regulatory standards. CDM, CFPPs document data such as observed food and fluid intake, calculation of nutrient intake, heights, weights, lab values, changes in diagnosis or health status, oral health, or other nutritional problems and status parameters for further assessment by the dietitian.
5. Identify Nutritional Problems: Through interviewing and observation, identify nutritional problems. Examples include: