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Lesson 7 Worksheet
Document Nutritional Information in the Medical Records
Angela Martin
United States University
WORKSHEET 7
2
Document Nutritional Information in the Medical Records
Worksheet
1.
quality care. The documents basically records particular observations, findings and facts about a
patients history, diagnoses, conditions, eating habits, interventions, treatments, skin conditions,
weight status, mental and physical functioning, lab values, nutrition related medications, fluid
and food intake. Its further important to document nutrition care so that doctor and medical
practitioner will have complete knowledge about patients prior nutritional background and
intervention. The nutrition care document of a patient verifies care given and are communicated
to state audits and health care team (OMalley, Grossman, Cohen, Kemper & Pham, 2010).
2.
What steps would you take to implement the AND (Academy of Nutrition and
WORKSHEET 7
measurements, medical procedures and tests, biochemical data and nutrition or food related
history.
Diagnosis: The accumulated data guides Registered Dietitian Nutritionist in selecting
3.
consumption of fruits, vegetables, liquid intake, type of meat consumed, number of water glasses
consumed on daily basis, intake of sugary intake and eating out.
4.
conditions affecting patients ability to maintain adequate nutrition and hydration. The topics
covered in this section are: nutritional approaches, weight loss, weight and height, and
swallowing disorders. The data in Section K are recorded by nurses for MDS.
5.
Twice a day
Mercury
Administered Orally
Four times a day
Fasting Blood Sugar
Chief Complaint
Ideal Body Weight
Basal energy expenditure.
Pounds
Chronic Obstructive Pulmonary Disease
Prealbumin test
WORKSHEET 7
4
GL
Stat
Glycaemic load
Medicine must be Administered Immediately
WORKSHEET 7
5
References
OMalley, A. S., Grossman, J. M., Cohen, G. R., Kemper, N. M., & Pham, H. H. (2010). Are
electronic medical records helpful for care coordination? Experiences of physician
practices. Journal of general internal medicine, 25(3), 177-185.