Charting is a critical responsibility for the dietitian and dietary manager in a long term care facility. Many times we may wonder why we have to chart in the first place. We do it to tell the person’s nutrition story both past and present and what the actions are for the future.
Charting, documenting and making a note all mean we are writing something in and for the record. Doing an assessment involves gathering information and determining how this relates to the person’s nutritional status and what we are going to do about it.
Charting terminology can include:
- Initial—base assessment and goals are established
- Quarterly—are care plan goals being met?
- Re-admissions—any changes since being in the hospital?
- Significant Change—this could be for a new TF or hospice admission
- Discharge—what is the resident’s status at discharge, is the care plan up to date, any education needed or provided?
- Annual—another base assessment
Let’s review each one noting some key points to remember:
Initial assessment: First of all read the medical record thoroughly and look at the history and physical. Check for any dietitian documentation and the last diet provided with the calories/protein indicated. It is also important to review current medications, in particular diuretics or appetite stimulant/depressants. Note the height/weight/BMI and estimated minimum needs. Labs need to be addressed along with pressure ulcers or other skin conditions. Indicate any edema, fluid loss or retention which can affect weight status. Speech/swallow evaluations need to be reviewed. It is also important to note if the resident was on a tube feeding or TPN while in the hospital or another facility and review any care plans.
Quarterly review: The quarterly assesses where resident is nutritionally compared to the care plan. Note how the resident is progressing, are their goals being met and if the interventions are working. This charting should support MDS documentation and care plan decisions. You do not have to repeat all the data gathered just a summary statement is usually sufficient.
Re-admissions: These notes are typically shorter than the initial or quarterly but some facilities may require a whole new assessment. Determine if nutritional status has changed or not. The hospital record should be reviewed and note any changes. There could be a new diet or eating ability; a new tube feeding or TPN or a weight change due to diuresing or re-hydrating. Look for any changes to skin condition along with any medication changes.
Significant Change: Most often involves doing a full assessment. The chart must be reviewed to determine what the significant change is. Resident’s with a significant change are often reviewed at the NAR (nutrition at risk) meetings. This significant change assessment becomes the new baseline. Care plan goals should also be adjusted if needed.
Discharge: Charting for discharge summarizes the nutritional status during the stay along with any educational material provided. It is key to have excellent discharge education so that re-hospitalizations can be prevented.
Annual: This is a full assessment which is similar to the initial and significant change assessment. The main difference is now you know the resident much better. Always read the record, observe the resident, adjust the care plan and summarize the year in review.
Other documentation: There may be other charting done in addition to the previously listed areas. This may include: observations, conversations with the resident or family, referrals, eating changes, wounds and weight changes.
Once you have mastered all of these key components you will be a charting champion at your facility!