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NUTRITION ASSESSMENT and DOCUMENTATION GUIDANCE 8

Nutrition Assessment Narrative A narrative of the comprehensive nutrition assessment is documented in the Care Plan Summary – Nutrition Assessment section. When writing the narrative portion of the nutrition assessment, CPAs should not duplicate information that is documented in other parts of the participant’s chart. Instead, CPAs should document their assessment of the information collected. Refer to the table below to help in determining what should and should not be included.

DO Include: DO NOT Include: Type of visit (IC, SC, NE-I, MC, HR f/u, etc.) Reason for remote certification. Pamphlets given or Education topics reviewed (Document on Nutrition Education screen instead). Growth/weight gain/weight loss – What caused the change? Include problems obtaining measurements (child uncooperative, physical limitations, etc.). Reasons for deferred blood work (caregiver refuses, participant is uncooperative, or the sample cannot be obtained, etc.). Nutrition Risk(s), unless clarifying or providing supporting information. Adequacy of diet (food groups lacking, portion sizes, food choices, beverage choices, etc). List of food items consumed, except for infants where it provides more information. Breastfeeding/formula feeding frequency and amounts (type of formula, any record of formula changes, problems associated with formula). Unapproved abbreviations Any unusual family dynamics (i.e., foster care, safety plan, guardianship changes, who accompanied the child to the appointment).

Conversations with doctors regarding formula changes, updated prescriptions, etc.

Any discussions or recommendations about health/diet concerns.

Follow up of any behavioral changes made since last visit or progress towards goals.

Food issuance problems (issuance from closet without inventory, exempt formula, food package modifications, etc) and tailoring (prescribed soy milk).

Referrals provided.