Implementing Care Plans

  • Provision of nutrition care for specific nutrition related problems
  • You would want to assesses the adequacy of the pt’s nutritional intake
  • Manipulate their diet
  • See if the pt needs enteral or parenteral support
  • Identify education needs of patient
  • Develop an intervention plan that involves counseling or education
  • Formulate an evaluation
  • Compliance Regulations
  • JCAHO – states that…
  • Pt’s must be identified for nutritional risk within 24 hours of admission.
  • In pt’s charts you need an assessment of the pt’s status, adequacy of their intake, appropriateness of the route of delivery, complications of the therapy, and outcome of the goals.
  • Communication regarding plans with:
  • Other Health Care Personnel-Documentation in a medical record chart allows the entire health care team to understand the rationale for nutritional care, the means by which it will be provided, and what each team members’ role is in its success.
  • Patients/families – You need to make pts involved in the goal making process – a pt is more likely to stick to a goal if he/she comes up with it themselves rather then if you assign one.
  • The dietitian should make sure that the patient and/or family members have a clear understanding of their nutritional status and the steps that should be implemented for their recovery or maintenance.
  • Discharge planning for continuity of care
  • You must provide notes to the facility that it going to take over the care of the pt (care givers, LTAC, etc). You must supply them with the nutritional therapies and outcomes of the pt, any pertinent info like weights and lab values, dietary intake, potential drug interactions, expected prognosis for the pt, and recommendations.
  • You also need to let them know of any necessary education, counseling, or resources that are needed by the facility to continue the pts care.
  • Documenting, appropriate charting techniques, and confidentiality
  • You must use black pen or it must be typewritten
  • Entries need the date, time, and service
  • Each page needs the pt’s name and hospital number on it
  • Entries in chronological order
  • Never make an entry in advance of performing the task
  • All entries must be signed including credentials
  • If you make an error, draw a single line through it and date and initial it
  • Chart everything that you do with/for the patient – if you don’t chart it, it’s like it never happened
  • Must comply with HIPAA regarding pt’s privacy
  • Pt’s must be notified if their medical information is to be shared.