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NUTRITION ASSESSMENT and DOCUMENTATION GUIDANCE 6

Nutrition Assessment Documentation The purpose of nutrition assessment documentation is to facilitate the delivery of meaningful nutrition services and to ensure continuity of care for participants. It is the primary means by which WIC staff communicate with each other about individual participants. It also improves program integrity and coordination with the health care community. Procedures Documentation should be • Consistent and organized: Staff should be able to easily find the information they need, i.e., required information is located in the same place in each chart. Duplication of information is minimized, and established standards/protocols are easily followed. • Clear: Other staff should be able to understand what the author is communicating. When in doubt, write it out. Staff should only be using Alabama WIC approved acronyms and abbreviations, refer to Appendix A in this document. • Complete and correct: It should create an accurate picture of the participant, the visit and his/her relevant issues, describes or lists the services provided over time and outlines a plan for future services. • Concise: It should only contain pertinent information and minimal extraneous information.

Paint a Picture Documentation should capture a picture of the participant’s visit in a manner that is easy to review, build upon and follow-up on at future visits. Use critical thinking to highlight the most important information collected in the different areas of the assessment (anthropometric, biochemical, clinical, diet and nutrition, and environmental). All participant files must include: 1) Assessment Information, including a) Supporting information for assigned risks. Weight, Height/length, Bloodwork (anthropometric and biochemical risks); Medical data (clinical/health/medical risks); Eating behaviors and feeding practices (dietary risks); Physical activity and other pertinent information (other risks) Note: staff must complete all required assessment screens and questions in Crossroads (MIS) to facilitate identifying all applicable nutritional risks. b) Participant’s needs and concerns. This information helps the CPA identify additional risks, nutrition education/counseling focus, and tailoring of the food package. 2) WIC Category and Priority level.