Documentation ASSOCIATION OF NUTRITION AND FOOD PROFESSIONALS. Amber Gordon RD LD Consultant Dietitian, Carolina Nutrition Consultants

Transcription

1 Documentation ASSOCIATION OF NUTRITION AND FOOD PROFESSIONALS Amber Gordon RD LD Consultant Dietitian, Carolina Nutrition Consultants

2 Objective Review nutrition documentation with focus on individualization and accuracy of key nutrition related information

3 Resident-focused Care Chart Review Interview Document Gather pertinent most up to date information Observe eating & nutrition habits Talk with resident, family, & staff Be detailed, specific & individualized

4 Screening Nutrition Screening Identify characteristics associated with nutrition problems, at nutritional risk, or malnourished Review: medical history, nutritional intakes (Food & Fluid), medications, physical condition/ changes to, anthropometric measurements, nutrition related laboratory data. High Risk residents Tube Feeding (new or change) Diagnosis of Anorexia, Cachexia, Dialysis or Failure to Thrive New pressure ulcers identified Significant weight changes Abnormal Albumin or Pre-albumin (low) Chewing or swallowing problems

5 CERTIFIED DIETARY MANAGER Accurate documentation Diet, snacks, supplements, feeding equipment Percent intakes/ specific information about acceptance Look at facilities documentation of meal intakes & compare to observations Dentition Obtain most up to date information Facility documented Height & Weight Documented within 24 hours admission or based facility Policy Height for clients with amputations (Pre-amputation Height) Utilize skin/wound reports/ body audits Review available labs

6 Weight Our main ESSENTIAL tool for nutrition assessment Accuracy of weight information and documentation aids effective use time Facility representative that drives the weight program Identified outlying weights/ possible weight inaccuracies Ensures timely re-weighing to avoid inaccurate documentation All documentation of weights need to be dated Data entry In all assessments

7 CALCULATING SIGNIFICANT WEIGHT CHANGES Previous weight (30, 90, 180 day) Current Bodyweight Previous weight (30, 90, 180 day) X 100 = % change 1-2% 1 week 5.0 % in 1 month 7.5 % in 3 months 10 % in 6 months

8 Usual Body Weight Usual body weight can be an essential assessment tool Request UBW from Resident, Family, or valid medical record Inquire specifically if they have noted a significant weight change prior to admit When doing quarterly or annual assessment look at available historical weight data

9 Insidious Weight Loss & Weight Trends Insidious weight loss: refers to a gradual, unintended, progressive weight loss over time During review weights: look at the WHOLE 6-month timeframe Are they above or below usual body weight? Evaluate for trends of weight gain or loss

10 Weight Record Examples INSIDIOUS WEIGHT LOSS WEIGHT TREND GAINING lbs 3/3/ lbs 2/3/ lbs 1/5/ lbs 12/2/ lbs 11/4/ lbs 10/7/ lbs 9/2/ lbs 3/3/ lbs 2/3/ lbs 1/5/ lbs 12/2/ lbs 11/4/ lbs 10/7/ lbs 9/2/14

11 Identification of possible weight inaccuracies lbs 3/3/ lbs 2/3/ lbs 1/5/ lbs 12/2/14 ** lbs 11/4/ lbs 10/7/ lbs 9/2/14

12 Thinking about significant weight changes Are there medical conditions or medications that could be associated with possible weight changes? CHF, ESRD, Dialysis, Anasarca, Ascites, Edema, Thyroid conditions, Diuretic medication, Appetite-affecting medications, Mood medications

13 Thinking about significant weight changes Physical Changes Increased walking/ physical activity/ initiation of therapy Functional difficulties eating Spitting food out Food loss from mouth, drooling Comprehensions feeding process

14 Meal Intake Documentation Review closely There should be NO HOLES Avoid documentation of Refusing with Alzheimer's/ dementia Consider if it could be an issue with the comprehensions of the feeding process If the plate is cleared does that always mean 100% consumed Is there spillage, drooling, pocketing, spitting food out, notable behaviors at meals?

15 Dealing with significant weight changes Think Food First Update food preferences Talk with resident Get family or caregiver input Would snacks be desired? Observe dietary habits Environment & Social Aspects Fridge in room? Family bringing in food snacks? Storing beverages or snacks in room What is the biggest meal of the day Eating habits prior to admit? Are they adequately understanding feeding process?

16 Food First Are ordered interventions working as intended? Snacks Avoid redundancy & provide snacks of the resident s choice Are snacks being delivered and passed on time? Continue to update preferences Should be completed for new admissions within 3 days or per facility policy Update often, recommend minimum with annual review (or per facility policy) Consider referral to facility programs Restorative dining, increased assistance for meals, identify barriers to adequate PO intake

17 Interdisciplinary Team Utilize the facility team to combat issues Work with SLP diet texture, thickened liquids, swallowing disorders Therapy for evaluation of feeding assistive devices Facility programs snacks, dining, activities with food Discuss significant weight or PO intake changes in Risk or IDT meeting

18 Diet Accuracy THIS IS YOUR DOMAIN be the Expert Ensure all residents have a Diet Ordered Physician orders drive all therapeutic diets and medical food orders Tray Cards must match Diet Orders The process of communication of diet and related orders are communicating the actual written physician orders Have a conversion tool & educate staff on House Diet Terminology

19 Contradictory or Confusing Diet Orders Renal, NAS A renal restriction includes salt restriction Regular Pureed Diet Mechanical Soft, Ground Meat, Finger Foods Pureed diet allow canned fruit, soft sandwiches, cracker, and soft desserts SLP needs to specify. This lacks specific guidance for dietary service & leaves too much to interpretation Diet As tolerated (Mechanical Soft Ground, offer Regular foods as tolerated)

20 Contradictory or Confusing Diet Orders Pureed Offer Finger foods No Seeds Fruits and vegetables w/ seed or particular ones No Milk Question : Allergy, Intolerance, Dislike? No Starch Just bread & rolls vs. all starchy foods Coumadin Diet Low K Vitamin K vs Potassium

21 Diet Orders Keep diets within house terminology, concise and clear Always think what will the diet staff need to fulfill this accurately If a specialized diet order is necessary it may require an extension to be written Avoid preferences being written in orders Orders must be followed so avoid putting things in orders that cannot be completed

22 Food Interventions Orders vs Preferences Example: a resident may express interest in Prune Juice as it helps avoid constipation. This can be an intervention to aid constipation but should it be an ORDER or a PREFERENCE Where ever the intervention is placed: Documentation needs to be completed Follow up/ effectives evaluation

23 Food Allergies and Intolerances Allergies deserve special attention from dietary managers Investigate What specifically is avoided? Whole Eggs VS any product that has egg in it Dairy Allergy VS Lactose Intolerance VS Dislike of milk What Reaction do they have/ what kind treatment would be needed Document thoroughly on this What does your staff need to know to serve your residents diet safely

24 SUPPLEMENTS These are medical foods which should be provided when ordered Monitor acceptance Is the timing, frequency and administration working? Monitor accuracy- physician orders matching administration Monitor shelf life, proper storage, labeling and dating

25 Tube feeding HOW TO CALCULATE % OF NEEDS RD typically evaluates a tube feed resident monthly to quarterly The RD s note will include the provision of nutrients provided by the ordered Tube feeding Calories, Protein and Fluid The RD s note will also include calculation of the residents estimated needs Calories, Protein and Fluid Calories provided by tube feeding X 100= % Calories from TF Estimated Calorie Needs If therapeutic feedings are being administered with tube feeding, documentation needs to be very specific about what and the amount being consumed

26 Continuity of Care working with your RD RD should be referred all High Risk residents Tube Feeding (new or change) Diagnosis of Anorexia, Cachexia, Dialysis or Failure to Thrive New pressure ulcers identified Significant weight changes Abnormal Albumin or Pre-albumin (low) Chewing or swallowing problems Know who your RD is following and utilize them effectively Notify if annual, quarterly, significant change documentation is upcoming on resident they will be seeing this month Refer and prioritize appropriate resident for review Prioritization

27 Remember Residents Choose Despite the healthcare clinical setting, this is home, this is their life Avoid Non Compliant or Refusing Our residents are participants in their care and if interventions are not working or therapeutic diets are not well accepted.. Should we consider liberalization? Documentation should have detailed information about them and their habits