document nutritional information in medical records Flashcards
What are the benefits of documentation?
Provides a standard of care, communication tool with other members of the healthcare team, required by government agencies, Lays the groundwork for a facility to receive compensation, a legal record, is a resource for monitoring quality of services, and is also part of quality standards for healthcare facilities.
What is included in the medical record?
Information to idenitfy the client, support the diagnosis, justify the treatement, and document the diagnosis and treatment.
What is included in the POMR?
Collection of data (info from client interview, health assessment, results from lab and radiology tests), A problem list (chronologic list of problems that the team needs to treat, date of onset, action taken, treatment or resolution, and date of the treatment), Plans for addressing each problem/ progress notes, and an evaluation summary including plans for follow up or referral.
What 5 steps are included in the nutrition care process?
- Nutrition Assessment (this includes nutrition screening)
- Nutrition Diagnosis
- Nutrition Intervention
- Monitoring
- Evaluation
What are the four parts of SOAP data?
Subjective information, Objective information, Assessment, and Plan.
What are the five areas of nutrition assesment?
- Food/ Nutrition- Related History
- Anthropometric Measurements
- Biochemical data, Medical tests, and procedures
- Nutrition- Focused Physical Findings
- Client History
What is the RAI?
The resident assessment instrument consists of three components and is utilized to assess each clients functional capacity and needs.
What is outlined in the MDS?
The form outlines the minimum amount of data that caregivers must collect and use.
What is covered in section k of the MDS?
- Swallowing disorder
- Height and weight
- Weight loss
- Nutritional Approaches
- Percent intake by artificial route
What are the four parts of nutrition screening?
A-B-C-D :
- Anthropometric measurements
- Biochemical tests or laboratory tests
- Clinical information
- Diet history
How do you figure ideal body weight for a woman?
100 lbs for first 5 feet in height + 5 lbs for each inch over 5 feet.
How do you figure ideal body weight for a man?
106 lbs for frist 5 feet in height + 6 lbs for each inch over 5 feet.
How do you adjust for frame size?
for a small frame, subtract 10% of the total
for a large frame, add 10% of the total
for heights less than 60”, subtract 2.5 lbs for each inch below 60”
How do you calculate percent of IBW?
Percent of IBW= (actual weight / IBW) x 100
What is the percentage of ideal body weight that would suggest that a person may be at nutritional risk?
below 90% ibw would suggest possible malnutrition.
What are the percentages of weight loss and the time frame that indicate nutritional risk?
weight loss of 5 % over the past one month, weight loss of 7.5 % over the past 90 days, a weigth loss of 10 % over the past 6 months.
How is protein calculated for a healthy adult?
.8 gms x body weight in kg
How is protein calculated for a malnourished client?
1.2-1.5 grams x body weight in kg.
How is protein calculated following surgery?
1.0-2.0 grams x body weight in kg.
How is protein calculated following trauma, severe burn, or multiple fractures?
2.0 grams x body weight in kg
What disease factors increase fluid needs?
fever, draining wounds, diarrhea, vomiting, hypertension, respirator, excessive perspiration, pressure ulcer.
What disease factors decrease fluid needs?
congestive heart failure, cardiac disease, renal disease, edema.
What are indicators of dehydration?
Client consumes less than 1500 ml of fluid daily, client has clinical signs of dehydration, client loses more fluids through vomiting, fever, diarrhea then they consume.
What is the daily fluid need for average adults?
30 ml per kg
