Food-Service-Manual-for-Health-Care-Institutions

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Food Service Manual for Health Care Institutions 270 Exhibit 9.2. Counseling, Education, and Discharge Planning Room no._____________________ Patient’s initialsa_________________________________________ Diagnosis_____________________________________________________________________________ Physician’s name_______________________________________________________________________ Counseling: R.D. provides data on nutrition or medical nutrition therapy_______________________ Consulted with interdisciplinary team________________ Individual counseling__________________ Family member present _________________________________________________________________ Comprehensive plan for education or discharge planning (any of the following that may be a hindrance to the education process) Psychosocial_____________ Spiritual___________ Cultural___________ Language barrier_________ Age______ Inability to read or write_____________ Emotional barriers_________________________ Economics of the care choice____________________________________________________________ Training in: Adaptive eating devices__________ Feeding pump_________ Portion control_________ Grocery shopping____________ Food preparation___________ MEDICAL NUTRITION THERAPY Name of modification __________________________________________________________________ Method used: Formal___________ Informal____________ Group sessions______________________ Tools used in education or discharge planning: (list) Audiovisual materials______________________ _____________________________________________________________________________________ Handouts_____________________________________________________________________________ Pretest________________________________________________________________________________ Food models __________________________________________________________________________ Other ________________________________________________________________________________ EVALUATION OF EDUCATION OR DISCHARGE PLANNING Ability of client or family to understand instructions_________________________________________ Will likely follow instructions: Client_____________________ Family__________________________ Client demonstrated learning took place by (list)____________________________________________ _____________________________________________________________________________________ Posttest_______________________________________________________________________________ Care plan was realistic and attainable, and goals were developed and agreed on by client or family___________________________________________________ Everyone can articulate outcome goals_________________________________________________________________________________ DISCHARGE PLANNING AND FOLLOW-UP Return appointment___________________________________________ R.D. telephone no. or e-mail address_______________________________________________________________________________ Community resources __________________________________________________________________ Home health________________________________ Hospice__________________________________ Referring physician_____________________________________________________________________ Public health (WIC/MIC) ________________________________________________________________ a Use patient’s initials only (per the Health Insurance Portability and Accountability Act). Document information in patient’s medical record. Note: Begin the counseling, education, and discharge planning after the screening data collection. Abbreviations: WIC, Women, Infants, and Children Supplemental Food Program. Source: Developed by Ruby P. Puckett, 2003. Used by permission.
earlier, the patient may need to be scheduled for outpatient dietary instruction or for a followup to an inpatient instruction. Immediately, the dietitian should carefully review the medical records of patients readmitted to assess whether a lack of nutrition intervention or an inadequate care plan led to the readmission. Documentation of Nutrition Care It is up to the individual facility to authorize specific staff members to make entries into medical records. If a full-time registered dietitian is not available on a regular basis, dietetic technicians or dietary managers may be authorized to record pertinent information about nutrition care plans. Documentation in a patient’s medical record may either be on a separate sheet that may be colored coded to designate the department, on an interdisciplinary sheet, directly on the physician’s progress notes, or on any other place designated by the medical records committee and policies and procedures of the organization. All entries must be dated, legibly written, preferably in black ink, words spelled correctly, and signed by the person writing the note and with his or her credentials. Never erase anything, cross out words, write “error” above the note or in any way change the message. Record missed appointments and poor or no compliance to outcome goals. To ensure that a procedure has been done, it must be documented. Accurate documentation of nutrition services provided to patients is vital to hospital systems for utilization management, quality control and assessment, and reimbursement. Basically, services are documented in the same way, and by the same staff members, as nutrition assessments and care plans. In addition to descriptions of the nutrition assessments, care plans, and services provided, the medical record should reflect periodic evaluations and revisions of the plan based on the overall effectiveness and objectivity of a patient’s treatment. The frequency with which nutrition services are recorded depends on a patient’s condition and the institution’s policies. For example, daily progress notes might be required for a critically ill patient or a patient whose condition is rapidly improving or deteriorating. A hospital policy might mandate a progress note each time a nutrition care plan is revised or reviewed, in which case a statement of the new plan or review findings would be included. Documentation is important for quality management because changes in status, especially incremental improvements, can be useful in justifying nutrition intervention. The actual format used for writing progress notes depends on the policies of the individual organization. Whatever the format, information should be as clear and concise as possible without omitting pertinent details. Usually, either source-oriented or problem-oriented medical records are used (Exhibit 9.3). In the source-oriented format, entries are structured according to the source of information, with entries included in order of occurrence. Nutrition care information should be included in the appropriately designated section of the medical record. In some organizations, the designated section may be the physician’s progress notes whereas in others a separate section is identified for ancillary departments. Entries are written in brief paragraph form; sentence fragments or key phrases are acceptable. The entry is signed with the name and title of the person writing it, the month, day, year, and time of day. The problem-oriented format focuses on the patient’s problems, personal profile, plans for care and education, assessment of progress, and results. An initial database consisting of the patient’s medical and social history is gathered in which problems are listed and assigned a number. The initial treatment of these problems is recorded, and progress notes are added as they pertain to specific problems in the problem list. An approach referred to as “SOAP” is used for each progress note, SOAP being the acronym for the elements of information in each progress note: • Subjective information: what the patient or family says • Objective information: what the facts relate about the patient’s progress, such as laboratory values, results of diagnostic tests, changes in weight, observations and examinations by health professionals, and nutrient intake calculated from diet history Clinical Nutrition Care Management 271
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Food Service Manual for Health Care
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Contents Figures, Tables, and Exhib
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Figures Figures, Tables, and Exhibi
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8.3. Excerpt from a Performance Eva
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19.1. Flow of Products in Food Serv
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6.2. Sample Job Description and Job
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Foreword It is truly an honor for m
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Preface The health care environment
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Acknowledgments The following indiv
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Introduction This edition of Food S
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Chapter 14 explains safety, securit
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Part One Management of the Food Ser
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Chapter 2 Leadership: Managing for
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oriented or people oriented and tha
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in an orderly manner, to manage the
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so as to anticipate and plan for fu
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Planning Through planning, the futu
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Reward or punitive power is the str
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• Building a team mind-set • Co
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of these three factors jeopardizes
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McClelland claims that “in some b
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• Define limits of what situation
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who have seen programs, processes,
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Leebov, W., and Scott, G. Health Ca
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Chapter 4 Quality Management A prim
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Figure 4.2. Deming’s PDCA Cycle A
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Move to CQI in Health Care The term
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care. Often these choices conflict.
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Supplier Partnerships A customer or
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analysis. Key benefits to having a
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Exhibit 4.1. Team Documentation For
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Figure 4.3. CQI Flowchart Quality c
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Exhibit 4.2. Inspection Criteria fo
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Once the departmental strategy is w
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Before hiring a consultant, managem
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selected for the issue in question.
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Figure 4.6. Cause-and-Effect Diagra
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not identical. CMS standards vary i
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the concurrent stay using critical
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Garvin, D. A. Managing Quality: The
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Chapter 6 Organization and Time Man
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Figure 6.1. Functional Organization
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Process departmentalization allows
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Characteristics of High-Performance
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outcome. Team building should conce
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necessary to assure that food servi
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Figure 6.4. Organization of a Small
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Figure 6.9. Organization of a Food
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skilled-nursing unit in the hospita
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service operations other than the c
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Distributing Authority Authority, t
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• What types of service does the
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Exhibit 6.1. (continued) Why? Which
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Exhibit 6.2. Sample Job Description
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equires, and the best means of moti
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Calculating FTE Needs Full-time equ
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Exhibit 6.3. Sample Productivity Fo
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Figure 6.10. Example of a Daily Sch
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Figure 6.12. Example of a Work Sche
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Figure 6.13. Example of a Manager
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Figure 6.14. Example of a Food Serv
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Lane, B. Managing People. Sunnyvale
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Page 248 and 249: Food Service Manual for Health Care
Page 277 and 278: Chapter 9 Clinical Nutrition Care M
Page 279 and 280: Planning As already shown, a manage
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Page 285 and 286: among professional staff whose memb
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Page 289 and 290: Nutrition service professionals can
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Page 297: • A constant and valuable source
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Page 307 and 308: Elements of an MIS In addition to t
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Page 327: Bibliography Alexander, J. Selectin
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Excerpt from Annual Food Service De
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Sample Monthly Operating Statement
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Labor Cost Analysis 334 Figure 11.5
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336 Exhibit 11.6. Example of a Mont
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Part Two Operation of the Food Serv
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352 Exhibit 12.2. Selection of Wast
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354 Exhibit 12.4. Selection of Wast
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Figure 13.6. HACCPs for Cook-and-Ch
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Restaurant-Style Health Care Menu f
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Chapter 16 Product Selection Produc
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Figure 16.2. Procurement Subsystem
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The USDA organic seal appears on fo
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Figure 16.5. Grade Stamps and Inspe
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A carcass of good grade is blocky a
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e accomplished by scalping, which p
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Table 16.1. (continued) Meat Descri
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harvesting and processing. This tas
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Poultry Poultry products or domesti
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Weight and Size of Shell Eggs Shell
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Table 16.3. Manufacturing and Inspe
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Eggnog Eggnog contains milk product
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Natural, Processed, and Imitation C
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Table 16.4. Common Cheeses Cheese D
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• Bamboo shoots • Bean sprouts
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Celery Celery, mainly the Pascal va
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Size is another factor that affects
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Fruit and Vegetable Specifications
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Corn, , sunflower, and safflower oi
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Organic Flour Organic flour is from
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Relatively small quantities of wild
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Herbal Tea Herbal teas do not come
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alloy, the result is stainless stee
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Summary Food service purchasers mus
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U.S. Department of Agriculture, Agr
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Chapter 18 Receiving, Storage, and
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Figure 18.1. Receiving System Items
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Merchandise Receipt Receiving, Stor
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Receiving, Storage, and Inventory C
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disposed of promptly. The storeroom
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Issuing of Food and Supplies Receiv
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A perpetual inventory record alone
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Inventory Turnover Slow inventory t
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Figure 18.2. Comparison of Par Stoc
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Receiving procedures must ensure th
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Appendix 19.1 A Culinary Glossary
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Hors d’oeuvre Side dish or relish
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Chapter 20 Distribution and Service
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• What is the best type of servic
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Figure 20.1. Typical Tray Makeup Li
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Tray Delivery Because the point of
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quality. In recent years, food serv
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carrying their filled trays to thei
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plate is not used. Place coffee or
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minimized. The type of meal service
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Standards that should be monitored
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Exhibit 20.2. Sensory Assessment fo
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Herz, M. L. Analysis of Alternative
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Index A ABC method, 603 Absenteeism
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CDC (Centers for Disease Control an
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Delivery of products, 575-576 Deman
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Exit interviews, 239, 240e Exotic v
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described, 461; developing, 461-463
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Horizontal communication tract, 194
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Main-dish salads, 652 Maintenance-m
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Nutrient analysis, 296 Nutrition aw
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PERT (program evaluation and review
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(1993), 4, 203; Federal Employee Po
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Standing operational planning. See
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Waste audit, 349 Waste-handling equ
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