Gettyimages 1133805261 Charting Resized

Medical records have always been a critical component in the healthcare/medical field, and this is especially true in long-term care settings. They contain data of the resident’s past and present health information and medical treatment, which tells the resident’s medical story and status.  Quality documentation is needed not only for regulatory compliance, but also for accurate MDS coding and reimbursement, and to provide quality healthcare to residents.

Documentation has become increasingly difficult as the resident’s clinical needs are more complex, regulations and surveys are more rigorous, litigations and legal challenges have increased, and documentation-based payment systems have been implemented. Dietitians work closely with the interdisciplinary team and nursing staff.  They consider the whole picture of a resident and their quality of life while upholding regulatory standards, facility expectations, and resident/representative demands.  In fact, CMS recognizes dietitians as experts in the industry and believes that dietitians are the professionals who are the best qualified to assess nutritional status and to design and implement an individualized nutritional treatment plan in consultation with the interdisciplinary care team.

The nutrition and hydration status of long-term care residents are areas that both state and federal surveyors pay close attention to, and rightfully so. Failure to identify residents at risk for compromised nutrition and hydration may be associated with an increased risk of mortality and other negative outcomes, such as impairment of anticipated wound healing, decline in function, fluid and electrolyte imbalance/dehydration, and unplanned weight change.

Referrals for dietitian documentation typically includes:

  • New/Readmissions
  • Annual/Significant Change in Status/Quarterly MDS
  • Significant Weight Loss/Gain
    • 5% x 1 month
    • 5% x 3 months
    • 10% x 6 months
  • Pressure Injury
  • Tube Feeding
  • Dialysis
  • Other Referrals from facility staff

Components of a Comprehensive Nutrition Assessment may involve:

  • Diagnosis – Any diagnosis triggering nutrition risk?
  • Malnutrition Score (if used by facility) – What is the reason they scored how they did?
  • Nutrition Focused Physical Exam – What are your findings?
  • Diet order – Is there a reason for therapeutic diet? Does the resident tolerate (i.e., chew/swallow difficulty, does not like, etc.)?
  • Appetite – How is the resident eating? Is it consistent with their normal level of functioning or has there been a change? Why has there been a change?
  • Height/Weight – Has there been a change from UBW or previous weight? Is there a Planned/Unplanned change? Is Reason for weight loss identified?
  • Medications – Are there any with potential nutritional side effects?
  • Labs – Any of nutritional concern? Reason for abnormalities
  • Skin – Any breakdown or risk for breakdown? Interventions in place?
  • Estimated Needs – Document formula used to calculate kcal, protein, fluid. Is the current diet supporting estimated needs with current intake?
  • Plan/Recommendations – Is there any follow up needed or recommendations warranted?

Monthly or High-Risk Charting may be comprised of:

  • Weight – Always make sure to look back 1, 3, and 6 months to capture any trends or weight changes; Document the reason for the weight loss; If weight change unavoidable or planned/beneficial make sure to document.
  • Diet Order – Is the resident tolerating? How are intakes?  Any recent changes?
  • Skin – Document on skin integrity. Weight changes can foreshadow altered skin integrity and vice versa.  Any improvements since you’ve last charted?
  • Medications – Any medications with potential SE’s? Diuretics?  Appetite Stimulants?
  • Labs – Any recent labs since you last assessed the resident? Rational for abnormal labs explained in note?
    • If on dialysis, are there dialysis labs? Are you communicating with dialysis RD and documenting communication?
  • Other –Anything else that puts the resident at risk for decline?
  • Plan/Recommendations – Is there any follow up needed or recommendations warranted.

Dietitians wear many hats in long-term care, with nutrition assessment, intervention, and monitoring and evaluation being keys to their role. Timely and effective nutrition documentation by a dietitian can help support MDS coding, reimbursement, and the need for skilled services all while promoting quality healthcare to residents.





  1. Medicare and Medicaid Programs; Part II-Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction. (2013, February 07). Retrieved from
  2. Centers for Medicare and Medicaid Services. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, (2017).