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Running head: WORKSHEET 7

Lesson 7 Worksheet
Document Nutritional Information in the Medical Records
Angela Martin
United States University

WORKSHEET 7

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Document Nutritional Information in the Medical Records
Worksheet

1.

Why is it important to document nutrition care in the medical record?


Its very important to document nutrition care in medical record in order to ensure high

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

Dietetics, formerly known as American Dietetic Association [ADA]) Nutrition Care


Process?
The Nutrition Care Process can be seen as a systematic approach that aims at giving ighquality nutrition care to patients. The Nutrition Care Process is a part of the Nutrition Care
Model. The underlying idea behind Nutrition Care Process is not that patients get similar care,
however the idea is that values and needs of patients are considered to make decision about their
healthcare needs. By effectively applying Nutrition Care Process greater recognition, effective
and efficient care can be given to patients in all care settings. The steps involved in Nutrition
Care Process are:
Nutrition Assessment: The Registered Dietitian Nutritionist gathers and documents
information for instance client history, nutrition-focused physical findings, anthropometric

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

suitable nutrition diagnosis.


Intervention: The Registered Dietitian Nutritionist then picks the nutritional intervention
directed towards the root cause of the nutrition diagnosis and problem meant to alleviate the

symptoms and signs of the diagnosis.


Monitoring/Evaluation: Evaluating and monitoring of whole process and Registered
Dietitian Nutritionist determines if individual has achieved the goal or not.

3.

What information should go into a dietary note?


The dietary note incorporates information relevant to meal plan of patient such as

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.

Who should record the Section K information for the MDS?


The section K for MDS is swallowing/nutritional status and this section evaluates the

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.

What does each of the following abbreviations stand for?


b.i.d
Hg
p.o
q.i.d
FBS
Cc
IBW
BEE
Lbs
COPD
PAB

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

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GL
Stat

Glycaemic load
Medicine must be Administered Immediately

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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.

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