DMA Practice Standards: Documenting in the Medical Record - Iowa ...

DMA Practice Standards: Documentingin the Medical RecordProfessional Standards of Practice serve as the basis for quality dietetic practice fordietary managers. The standards that follow provide guidelines for dietary managers touse when documenting food history, food preferences, and food intake in the medicalrecord.Other Practice StandardsDietary Department Catering >>Controlling Costs in Food Service >>Sanitation >>Documenting in the Medical Record >>Calculating Food Costs >>Estimating Staffing Needs >>Determining Menu Item Prices >>Menu Planning, Calories, and Portion Sizes >>Food Storage: Refrigerated, Frozen and Dry Foods >>Documenting Fluid Intake >>Last Updated June 2005(Revision in process August 2008)Professional Standards of Practice serve as the basis for quality dietetic practice fordietary managers. The standards that follow provide guidelines for dietary managers touse when documenting fluid intake in the medical record.Standard 1:The certified dietary manager (CDM) shall ensure that nutritional screening, foodpreferences, and food acceptance are accurately obtained, monitored, and recorded in themedical record in accordance with state regulations and facility guidelines. The CDMshall ensure that food/fluid- related interventions are added to plans of care.

Criteria1.1 Nutritional screenings are obtained from clients in a timely manner that comply withregulatory agency guidelines.1.2 Managers use standardized forms for recording nutritional screening.1.3 Qualified dietary staff will receive training to obtain nutritional screeninginformation.1.4 Food preferences/nutritional screening/fluid intake will be entered into the medicalrecord by qualified staff according to state regulations.1.5 All medical records are legal documents; entries in the medical record will be in blackink, dated, signed with full name and title, and never backdated or erased. Chart errorsare corrected by a one-line strike out, initialed, dated, and labeled “error.”1.6 In cases where facilities have an individual’s record maintained by computer, ratherthan hardcopy, electronic signatures are acceptable. Following are guidelines for acomputerized record system:1.6.1 There is a written policy, at the healthcare facility, describing the attestation policyin force at the facility.1.6.2 The computer has built-in safeguards to minimize the possibility of fraud.1.6.3 Each person responsible for an attestation has an individual identifier.1.6.4 The date and time is recorded from the computer’s internal clock at the time ofentry. An entry is not to be changed after it has been recorded.1.6.5 The computer program controls what actions/areas any individual can access orenter data, based on the individual’s personal identifier.1.7 Progress notes reflect visual checks of amounts of client’s food intake and anyabnormal food behavior.1.8 Food intake information collected during meal rounds will be part of the nutritionalscreening document and shall be concise, timely, and reflective of the client’s currentcondition.1.9 Visual food intake information is part of the nutritional screening and will include thefollowing:1) client does not consume 25 percent or more of food for two out of three days,2) client does not consume all/ almost all of fluids for two out of three days,3) client’s ability to chew or swallow,4) client has difficulty using regular feeding utensils/dinnerware.

1.10 Progress notes will also include a visual check of the dining environment (does theenvironment encourage residents to eat, provide a desirable social setting for meals, etc.).1.11 Interventions are planned with the dietitian to address family, staff, or resident’sfood concerns and manager’s information shall be added as approaches to the care plan.Assessment1.1 Copies of recent surveys indicate compliance with regulatory agency guidelines.Problem areas are noted and plans of correction are developed by the CDM withdietitian* consult.1.2 Standardized forms are available and acknowledged by the administrator anddietitian.*1.3 Standardized parameters for anthropometric data, biochemical data, physical examdata, and client history data have been established by the facility and approved by thedietitian.* (Examples of parameters can be found in the following document: NutritionDiagnosis and Intervention: Standardized Language for the Nutrition Care Process bythe American Dietetic Association.)1.4 Records, that include objectives of training, competency recorded, and time frame,are completed and filed.1.5 Copies of recent surveys indicate compliance with regulations regarding recording inthe medical record.1.6 Sufficient progress information exists to document change toward achieving care plangoals.1.7 Medical records are audited for correctness of recording and appropriateness of theinformation either quarterly or per facility policy.STANDARD 2:The certified dietary manager shall ensure that procedures for documenting nutritionalassessment are established according to regulatory agency guidelines or facility policies.Criteria1.1 The certified dietary manager works with the dietitian* to establish a nutritionalassessment documentation procedure.1.2 Managers use standardized forms for recording assessment data.

1.3 All medical records are legal documents; entries in the medical record will be in blackink, dated, signed with full name and title, and never backdated or erased. Chart errorsare corrected by a one-line strike out, initialed, dated, and labeled “error.”1.4 In cases where facilities have an individual’s record maintained by computer, ratherthan hard copy, electronic signatures are acceptable. Following are guidelines for acomputerized record system:1.4.1 There is a written policy, at the healthcare facility, describing the attestation policyin force at the facility.1.4.2 The computer has built-in safeguards to minimize the possibility of fraud.1.4.3 Each person responsible for an attestation has an individual identifier.1.4.4 The date and time is recorded from the computer’s internal clock at the time ofentry.1.4.5 An entry is not to be changed after it has been recorded.1.4.6 The computer program controls what actions/areas any individual can access orenter data, based on the individual’s personal identifier.1.5 Certified dietary managers document nutritional screening data such as p/o intake,heights, weights, lab values, changes in diagnosis, oral health status, or other parametersassessed by the dietitian.1.6 Certified dietary managers will review intake records, do visual meal rounds, anddocument actual dietary intake.Assessment1.1 The policy and procedure for nutritional assessment, signed by administration and thedietitian*, is on file in the dietary department.1.2 Standardized parameters for anthropometric data, biochemical data, physical examdata, and client history data have been established by the facility and approved by thedietitian. (Examples of parameters can be found in the following document: NutritionDiagnosis and Intervention: Standardized Language for the Nutrition Care Process bythe American Dietetic Association, 2007, pg. 22-41.)1.3 Standardized forms are available and acknowledged by appropriate staff per facilitypolicy.1.4 Sufficient progress information exists to document all changes toward achieving careplan goals.Summing it UpThese guidelines offer help for CDMs responsible for documenting food history,preferences, and intake. Refer to them as needed.

*Dietitian refers to one or more of the following credentials: Registered Dietitian (RD),Licensed Dietitian (LD), Certified Dietitian (CD).Thanks to the 1998-99 Professional Standards Steering Committee for their review andassistance with this document: Kathleen Deckard, CDM, CFPP; Barbara Holly, CDM,CFPP; Scott Terle, CDM, CFPP; Mary Ellen Posthauer, RD, CD; Hal Lottis, CDM,CFPP; Kristi Salisbury, CDM, CFPP, RD, LD; and Donna Gavin, RD, LD.