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

• Gives patients greater protection of their medical records
• Holds violators accountable with civil and criminal penalties
• Imposes new restrictions on health care providers, health plans, health care clearing
houses, and business associates who have access to medical records and determines who
may conduct electronic transactions (for more information, see the Web site of the
American Health Information Management Association [http://www.ahimacampus.org]
or their manual listed in the Bibliography.
Summary
The role of a nutrition manager is similar to that of other health care managers. Planning
includes creating policies and procedures for providing nutrition care, writing goals and objectives
consistent with those of the department, and developing and marketing new programs.
Organization of the nutrition section of the food service department depends on the size of the
facility and patient types. The nutrition team generally consists of some configuration of nutrition
managers, R.D.s, dietetic technicians, nutrition assistants and aides (or clerks), and hosts
and hostesses.
The nutrition manager must develop and use leadership skills that motivate the staff
toward the department and organization’s vision. Financial expertise on the manager’s part has
become increasingly important with the demand for cost-effective services. The nutrition manager
must seek to prove the necessity of nutrition intervention in health care delivery through
the measurement of positive patient outcomes.
Patient nutrition services include screening to determine nutritional risk, assessment and
reassessment, education, and discharge planning. All of these are accomplished through the use
of care plans and may be based on interdisciplinary critical paths. In addition, the nutrition
staff may provide intervention through enteral or parenteral feeding. Regardless of what nutrition
intervention or treatment is provided, the care must be fully documented in the appropriate
section of a patient’s medical record. Entries must be made by the person performing the
treatment. When verbal orders are given, the order should be noted in the patient’s medical
record as a verbal order and tabbed for the physician’s signature at a later date, usually within
24 hours.
Bibliography
American Dietetic Association, Future Practice Roles Task Force. Future Report to the House of
Delegates. 2001. [http://www.eatright.com/qm/standards.html].
American Health Information Management Association. Boost Your Expertise with HIPAA and
Privacy Tools from AHIMA. Chicago: American Health Information Management Association,
2003.
American Hospital Association. Recording Nutrition Information in Medical Records [Management
Advisory]. Chicago: American Hospital Association, 1990.
Bradley, R. T., Ebbs, P., Young, W. Y., and Martin, J. Characteristics of advance-level practice: A
model and empirical results. Journal of the American Dietetic Association 93:196–202, 1993.
Briggs Corporation. Minimum Data Set and Resident Assessment Protocols–Version 2.0. Des
Moines, Iowa: Briggs Corporation, Sept. 2000.
Charles, E. J. Charting by exception: A solution to the challenge of 1996 JCAHO’s Nutrition Care
Standards. Journal of the American Dietetic Association 97(2):5131–5138, 1997 [suppl.].
Christakis, G. (ed.). Nutritional assessment in health programs. American Journal of Public Health
63(11), 1973 [suppl.].
Clinical Nutrition Care Management
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