FN 255: Introduction to MNT
  Teresa (Snyder) McFerran, MS, RD
Health Professions Division
Lane Community College
Eugene, Oregon
Unit 2 Preparations, Chapter 2
Nutrition Assessment

Unit 2 Study Questions DUE before midnight (11:55 pm) SUNDAY


ACTIVITIES AT A GLANCE. Check them off as you complete them.
ck
 By midnight (11:55 pm) SUNDAY complete Unit 2 Study Questions for 10 points (be certain you've FIRST done filled in the Unit Preparation Outline). (If you have any questions, post them in our "Forum Week 2" in Moodle.)
ck
 Sometime BEFORE SUNDAY participate in our Forum Week 2" by making at least two postings throughout the week with at least one of the postings BEFORE Friday evening. So the total MINIMUM is 2 postings on TWO different days. (A posting can be either posting a question you have or replying to a classmate's question or comment. You don't have to respond to all of the threads if you don't feel you have anything to add. You can also choose to respond more often.)


OBJECTIVES

After reading the assigned reading, filling out the Unit Outline (printed from Moodle), participating in the "Forum Week 2", and completing the Unit 2 Study Questions, you will be able to:
RESOURCES

WEEKLY FORUMS:
Each week, there will be a FORUM that will allow you to post any questions you have about the lecture or materials covered as well as allow the instructor to post any changes or corrections that need to be communicated.

A SQ will ask if you participated at least twice in this week's forum. (Refer the syllabus for additional details.)

FORUM WEEK 2: (Go to our Moodle classroom and click on "Forum Week 2" to participate.)
  1. "Student Questions": Do you have any questions about the Unit 2 Preparations? Please post your questions/concerns in the forum for others to be able to respond.

  2. "Nutrition Screening versus Nutrition Assessment": Based on the information covered in the Unit Preparations this week, how are nutrition screening and nutrition assessments similar and different?

  3. "Nutrition Interview": This week you will be interviewing a family member, friend classmate, or co-worker to complete a nutrition screening and 24-hour food recall. After completing the Unit Preparations for the nutrition screening and 24-hour food recall, please share your experience and what you learned from obtaining this information.

  4.  [Certified Dietary Manager (CDM) students only MUST answer this FORUM QUESTION]:

What is a Resident Assessment Instrument (RAI)?
Describe the 3 components of the RAI.
What is the role of the CDM in completing section K of the MDS?


Unit 2 Preparations, Chapter 2
Nutrition Assessment
The Unit 2 Study Questions will be based on the answers you obtain from filling in ALL of the blanks and checking out the links for the Unit 2 Preparations below. Filling out the unit preparations is the best way to prepare for the SQ, and considering all quizzes are timed, you will not have ample time to complete the quiz if the Unit Preparations are not completed first.

The following topics will be covered this week:
I.  The Healthcare Team

II. Nutrition Screening and Nutrition Assessment

III. Overview of Regulatory Agencies and Documentation

IV. Chapter 2: Nutrition Assessment


I. The Healthcare Team

In order to provide high-quality care, there must be ongoing communication among members of the healthcare team. This assures that the team effectively evaluates the needs of each patient and develops cohesive, comprehensive, workable plans for care.

Providing medical care is a complex task and requires many different types of expertise. Professionals in many healthcare disciplines contribute this expertise. The healthcare team is a group of professionals, each with unique training and expertise, who contribute to the overall care of a client.

The nutrition professional providing MNT is usually part of a healthcare team. The following members typically comprise the health care team:
Let's take a look at some typical roles and responsibilities for members of the healthcare team below as they relate to high-quality nutrition care (This list is a based on the information available in Nutrition & MNT for Dietary Managers by Sue Grossbauer):
Healthcare Team Member
 "Nutritional" Responsibilities
 Educational Background
 Professional Website
RD
  • Assumes primary responsibility and accountability for nutrition screening and assessment and resident nutrition care planning
  • Selects and sets up nutrition screening/assessment system (in cooperation with the nursing service and facility administration); trains facility staff as needed
  • Monitors the screening system
  • Performs nutritional assessments
  • Develops nutrition care plans
  • Records assessment findings, recommendations, and follow-up plans in medical record
  • Alerts other team members to any part of the nutritional care plan needing their cooperation
  • Defines the role of a dietary manager and provides training
  • Provides nutrition counseling
  • Monitors the accuracy of diet service
  • Participates in quality management

http://www.eatright.org/
CDM
  • Interviews clients for diet history
  • Conducts routine nutrition screening/collects data for assessment
  • Calculates nutrient intake
  • Implements diet plans
  • Documents nutrition information on client's medical records
  • Counsels clients on basic diet restrictions; specifies standards and procedures for food preparation to comply with diet restrictions
  • Evaluates effectiveness of nutrition care plans
  • Assists in nutrition care process according to established policies and procedures

http://www.anfponline.org/
RN
  • Assesses client needs; develops, implements, and monitors care plan
  • Delivers direct nursing care
  • Ensures that resident consumes food; organizes the resident feeding responsibilities, distributes the workload, determines need for adaptive eating devices with input from OT
  • Assists with mealtimes and feeding
  • Records accurate and meaningful information about client's food and fluid intake
  • Provides education to clients

http://www.nursingworld.org/
Administrator
  • Ensures that a nutritional screening/assessment system exists
  • Ensures adequacy of staffing to implement and maintain the system
  • Supports all staff members in performing their duties
N/A (often RN background)
MD
  • Evaluates medical conditions and develops diagnoses
  • Plans, oversees, and monitors treatment
  • Bears major responsibility for the nutritional status of the resident (in conformance to acceptable standards of practice)
  • Writes diet orders and/or approves protocol for standard orders
  • Orders other treatments which affect nutritional status
  • Utilizes information provided by other members of the healthcare team

http://www.ama-assn.org/
SW
  • Evaluates social and support needs
  • Assists patients and families with decision-making
  • Helps clients and families plan care upon discharge from a healthcare institution
  • Assists with applying for other healthcare services, such as home-delivered meals or home care
  • Identifies resources
  • Provides counseling

http://www.socialworkers.org/
SLP
  • Evaluates chewing and swallowing function of residents
  • Recommends appropriate therapy for dysphagia (difficulty swallowing)
  • Provides evaluation and therapy for speech-related needs

http://www.asha.org/
OT
  • Evaluates needs related to fine motor skills
  • Often recommends assistive eating devices and other techniques to help patients feed themselves
  • Provides therapy to develop fine motor skills

http://www.aota.org/



II.  Nutrition Screening and Nutrition Assessment

Nutrition assessment is the first step in the Nutrition Care Process.  The Nutrition Care Process provides a standardized process of providing care to clients.  It involves four steps:
  1. Nutrition Assessment- collecting information to identify nutrition risk, and verifying and evaluating data collected.  This step also includes nutrition screening.
  2. Nutrition Diagnosis- defining all nutrition related problems using standardized terminology defined by the Academy of Nutrition and Dietetics.
  3. Nutrition Intervention- a plan of care to correct a nutrition problem.
  4. Nutrition Monitoring and Evaluation- following up to determine how well the interventions are working.

Nutrition assessment is usually preceded by nutrition screening to identify clients or groups who are at risk for nutritional disequilibrium and who may require nutrition intervention.

Nutrition Screening identifies individuals at risk for nutrition problems.  It is part of the first step in the Nutrition Care Process.  In a healthcare facility like a hospital or skilled nursing facility, every admitted individual should undergo a nutrition screen to see who may need nutrition therapy.  Screening involves comparing specific client characteristics to cut-off points or factors, also known as indicators or "triggers", associated with nutritional risk. Indicators are pieces of information that might suggest a concern or risk. Many are numbers or measurements, whereas others might be based on diagnosis, usual food intake, or laboratory data.

The screening protocol depends on the group under study, the environment, the available resources, and the purpose of identifying those clients at risk. The methods used should be sensitive enough to identify clients at nutritional risk. The person who conducts nutrition screening may be a dietary manager, dietary technician, or other caregiver as dictated by institutional policy.

An effective nutrition screening process includes the following:

Click on the following link to review a nutrition screening done at Corvallis Manor Nursing & Rehab and then answer the questions in your Outline:
Corvallis Manor Nutrition Screen

Print the Nestle Mini Nutritional Assessment and interview a family member, friend, classmate, or coworker to answer letters A-F. Complete ONLY the screening section letters A-F, NOT the assessment sections letter G-R.

Note: This week's Unit Preparations for Chapter 2 will also require you to interview a family member, friend, classmate, or coworker to complete a 24-hour recall. You are welcome to interview the same individual for both assignments. Therefore, you may want to read Chapter 2 and review Figure 2-4 on page 64 prior to completing the Nestle Mini Nutritional Assessment.

Review the AND (formerly ADA) Nutrition Risk Assessment and answer the questions in your Outline:

Even a nutrition risk scoring system may incorporate certain overrides or automatic flags. Overrides or automatic flags can be helpful to be certain that individuals who might benefit from the MNT receive appropriate assessment. For example, a patient who has been NPO (nothing by mouth) or received only clear liquids for more than 5 days will automatically be considered to be at high nutritional risk at many facilities.

Many sources and standards exist for nutrition screening. Tools vary from one institution to another. If you join the staff of a healthcare institution, you will most likely find that there is a tool in place. Refer to the MNT prioritization from Sacred Heart River Bend in Eugene, OR and answer the questions in your Outline:
   
    Sacred Heart River Bend Initial Nutrition Prioritization Guidelines
    (If the link above is not working, refer to the pdf file of this link posted under Week 2 in Moodle.)

Note: Most likely you will not recognize most of the diagnostic terms used in the Prioritization Guidelines above, but knowing basic medical terminology is a must for anyone who screens and/or assesses patients in a healthcare facility. Throughout this term we will discuss many of the terms and diagnoses for you to begin building a stronger base in medical terminology, or build on your current base if some of the terms are already familiar to you.

Patients whose nutrition screening suggests concerns then need a nutrition assessment.

Nutrition Assessment: This is an in-depth evaluation of a client's nutritional well-being. Ordinarily, the person who performs a nutrition assessment is a registered dietitian (RD).

The nutritional assessment is the basis for the nutrition care plan and formulation of goals. These goals should be made with the client or family members whenever possible, should be realistic and measurable, and should have specific action plans. The patient's nutritional status must be evaluated before intervention is initiated, and should be revisited throughout the course of care.

Components of a complete nutrition assessment include the following:
 Another way to remember the different components of a nutrition assessment (and nutrition screening indicators) is to learn the ABCD's.


The Four Components of a Nutrition Assessment:
No single component or assessment tool is sensitive and specific enough to be used as the sole indicator of nutritional status. Therefore, a variety of components are used in conjunction to provide a more comprehensive and accurate nutrition assessment of the individual.


Note: We will build on the definitions of nutrition assessment and nutrition screening above as we cover Chapter 2 of our text and apply the information covered in our two Comprehensive Case Studies this term. Therefore, if this is still a bit murky you will have additional opportunities to clarify the similarities and differences between the two processes.

III. Overview of Regulatory Agencies and Documentation

The problem of malnutrition in hospitalized patients was revealed in a 1974 article, “The Skeleton in the Hospital Closet,” by Charles Butterworth, Jr, MD, and published in Nutrition Today. Today, malnutrition in hospitals remains a serious issue. It occurs worldwide and affects patients of all ages—from infants in the neonatal intensive care unit (NICU) to geriatric (elderly) patients. Malnutrition has been associated with an increased length of hospital stay, increased morbidity and mortality, impaired respiratory and cardiac function, decreased immune function, and poor growth in infants and children (Fessler TA. Malnutrition: a serious concern for hospitalized patients. Today's Dietitian. 2008;10(7):44).

Nutrition screening and assessment processes are generally dictated by relevant healthcare regulations, both federal and state. In the mid-1990s, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated that hospitals establish nutrition screening and assessment guidelines. Standards may require that nutrition screening be conducted within a given timeframe after admission, and again at prescribed intervals. Based on regulations, the roles of nutrition professionals in screening and assessing may vary from one institution to another. Likewise, the method of documenting screening and assessing activities may also vary.

At most healthcare facilities, nutrition screening should occur within the first 24 hours of admission. Nutrition screening helps a nutrition professional identify healthcare clients in need of nutrition intervention. It is also required in compliance with regulations and standards. Screening criteria usually include weight and height, recent weight change, oral intake, and sometimes diagnosis and/or other comorbidities.

The nutritional education and training of many physicians is limited. In 1985, the National Academy of Sciences found that U.S. medical schools required an average of only 21 hours of nutrition instruction and only 27% of the schools surveyed had a specific required nutrition course. Therefore, it is imperative that nutrition experts are part of the healthcare team and contribute to providing excellent care.

However, in a healthcare environment, it is not enough to provide excellent care. It is also critical to document all medical care, including nutrition-related care. The following list is adapted from Nutrition & MNT for Dietary Managers by Sue Grossbauer, which describes a handful of purposes documentation serves:

Refer to the following link to answer the questions in your Outline:

    CMS Revised Guidance for Long-term Care

Click on the links below to answer the questions in your outline:

05-008 Pinnacle Nutrition Care Plan (handwritten)
AHT Nutrition Care Plan (computerized)



Health Insurance Portability and Accountability Act (HIPAA):

In April 2003, a security regulation called HIPAA took effect. HIPAA stands for Health Insurance Portability and Accountability Act, a federal law intended to protect the privacy of healthcare patients and clients, which also standardized the exchange of healthcare information. If you work in a healthcare facility, the manner in which you handle medical records and related documents will be guided, in part, by HIPAA. HIPAA regulations dictate that patient information and health-related data will be kept private and secure. This affects confidentiality practices, how healthcare providers handle any medical documentation, and how computer systems that contain patient information are managed.

United States Department of Health & Human Services (HHS) has many online resources about HIPAA, both for health care consumers and organizations who serve those health care consumers.

A major aspect of HIPAA is the Privacy Rule. The 2 minute video in the link below is was produced to help consumers of healthcare understand their rights.

HIPAA video

Below are excerpts from the HHS Summary of the HIPAA Privacy Rule, the purpose of which is to assist health care organizations interpret and implement the Privacy Rule.

"Privacy Policies and Procedures:
A covered entity must develop and implement written privacy policies and procedures that are consistent with the Privacy Rule.
Privacy Personnel:
A covered entity must designate a privacy official responsible for developing and implementing its privacy policies and procedures, and a contact person or contact office responsible for receiving complaints and providing individuals with information on the covered entity’s privacy practices.
Workforce Training and Management:
Workforce members include employees, volunteers, trainees, and may also include other persons whose conduct is under the direct control of the entity (whether or not they are paid by the entity).    A covered entity must train all workforce members on its privacy policies and procedures, as necessary and appropriate for them to carry out their functions.    A covered entity must have and apply appropriate sanctions against workforce members who violate its privacy policies and procedures or the Privacy Rule.
Mitigation. A covered entity must mitigate, to the extent practicable, any harmful effect it learns was caused by use or disclosure of protected health information by its workforce or its business associates in violation of its privacy policies and procedures or the Privacy Rule.
Data Safeguards:
A covered entity must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of protected health information in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure.    For example, such safeguards might include shredding documents containing protected health information before discarding them, securing medical records with lock and key or pass code, and limiting access to keys or pass codes.
Complaints:
A covered entity must have procedures for individuals to complain about its compliance with its privacy policies and procedures and the Privacy Rule.71 The covered entity must explain those procedures in its privacy practices notice.
Among other things, the covered entity must identify to whom individuals can submit complaints to at the covered entity and advise that complaints also can be submitted to the Secretary of HHS.
Retaliation and Waiver:
A covered entity may not retaliate against a person for exercising rights provided by the Privacy Rule, for assisting in an investigation by HHS or another appropriate authority, or for opposing an act or practice that the person believes in good faith violates the Privacy Rule.    A covered entity may not require an individual to waive any right under the Privacy Rule as a condition for obtaining treatment, payment, and enrollment or benefits eligibility.
Documentation and Record Retention:
A covered entity must maintain, until six years after the later of the date of their creation or last effective date, its privacy policies and procedures, its privacy practices notices, disposition of complaints, and other actions, activities, and designations that the Privacy Rule requires to be documented."

If you are interested in additional information about the Privacy Rule, you can find the complete summary from HHS at this link: Summary of the HIPAA Privacy Rule


Common Abbreviations for Medical Records:

Please familiarize yourself with the list of common medical abbreviations for medical records (Figure 7.6 on the first page of the document posted in week 2 in Moodle.)
You will be quizzed on some of these medical abbreviations throughout the term.

IV. Chapter 2: Nutrition Assessment

Read chapter 2 in your text and answer the questions in your Outline.

*Print the 24hour recall form to fill out as you go through questions 1-7 in Figure 2-4.

************************************************************************************************************************************************************
THIS SECTION IS TO BE COMPLETED BY CDM (Certified Dietary Manager) STUDENTS ONLY:

 Resident Assessment Instrument (RAI)

Healthcare facilities participating in the Medicare and Medicaid programs must follow federal regulations developed by the Centers for Medicare & Medicaid Services (CMS), which include certain documentation in a standardized format.  Both licensure of the institution and reimbursement for services depend on proper documentation. Individual states enforce the regulations.  A centerpiece of the CMS regulations is the Resident Assessment Instrument (RAI).  The RAI helps the interdisciplinary team to assess and plan high-quality care.  This  documentation piece is required above and beyond the medical record that is already maintained in order to receive funding from Medicare and/or Medicaid.  

See the document in Week 2 Moodle for more information on the Resident Assessment Instrument (CDM students only)
End of Week 2 Unit Preparations

After filling in ALL of the blanks to the questions above go to the
 "Unit 2 Study Questions" under Week 2 in Moodle to submit your answers.
(Note: If you take the quiz after the due date, please send me a message. It will probably not be graded
until you do that as I may not realize it was done. I can do this ONE time.)