NUTRITION EDUCATION WPPM #400-12 Subject: Nutrition Education Requirements Item: Care Plan

Feb 1, 2022 California WIC Policy and Procedure Manual PURPOSE: Ensure consistent documentation of Care Plan notes in the WIC Web Information System Exchange (WIC WISE) to provide continuity of care. The Care Plan and subsequent follow-up notes outline the health and nutrition assessment, nutrition education provided, and goals set by the WIC participant. POLICY: I. Local agency (LA) Competent Professional Authority (CPA) must document a new Care Plan at each certification and recertification in WIC WISE. A. Components within the Care Plan must be updated at specific contacts within the certification period. Refer to the Care Plan Minimum Standards. B. Care Plan documentation must be consistent and contain the required elements. Refer to the Care Plan Minimum Standards. C. Only one Care Plan may be created per certification period. PROCEDURES: I. Document the following components in the Care Plan: A. Assessment Grid. Include the following elements at certification and recertification: 1. Brief description of participant’s concerns/issues. 2. Any concerns regarding height, weight, or bloodwork. 3. Brief description of any urgent concerns including mental health, substance abuse, food security, housing etc. 4. Topics discussed and education provided. 5. Any important information needed for future contacts. 6. Source of any important health information that did not come from WIC referral form. 7. Reason for any High Risk (HR) follow up referral. Document if HR referral is refused. 8. When a Note was also created in the Breastfeeding Support and Notes section. 9. Explanation when response selected is “other health or medical problem not listed in the dropdown”. 10. Clarification for any manually assigned risks. Page 1 of 3

NUTRITION EDUCATION WPPM #400-12 Subject: Nutrition Education Requirements Item: Care Plan

Feb 1, 2022 California WIC Policy and Procedure Manual Page 2 of 3 B. Goal Grid. An active goal must always be present. Document in grid if participant refuses to state a goal. 1. At certification, the CPA must document a new goal in the Care Plan. The goal must be clear and realistic and describe the following information: a. What the participant plans to do as a goal. b. How the participant will complete the goal. c. When the planned action will occur. 2. At recertification, the CPA must: a. View and update the goal from the previous Care Plan. b. Add a new Care Plan and complete as described above. C. Follow Up Grid. Grid is completed at mid-certification, and individualized nutrition counseling contacts during a certification period that do not follow a class script. 1. Contacts that are not high risk. a. Review assessment and follow up notes for certification period. b. Review current goal and update status. Add new goal when previous goal was “Met" or "Not Met". c. Add a row in the Follow Up grid and include the following in the Notes: i. Participant’s current concerns/issues. ii. What was discussed and what education was provided. Document refusal as appropriate. iii. Any important information needed for future contacts. iv. When a note was also created in the BF Support & Notes. 2. High Risk Contacts. a. Review current goal and update status when related to HR. b. Add a row in the Follow Up grid and include the following in the Notes: i. Participant’s current concerns/issues related to the HR condition ii. What was discussed and what education was provided. iii. Any important information needed for future contacts. iv. When the next HR contact will occur. Provide explanation if no additional HR follow up is needed (i.e., HR is being followed by Healthcare Provider, or HR is resolved).

NUTRITION EDUCATION WPPM #400-12 Subject: Nutrition Education Requirements Item: Care Plan

c. When an HR contact occurs on the same day as the certification or recertification completed by another staff: i. In the assessment grid, write RD/DN Note and then add elements outlined above for the HR contact. ii. Record nutritionist initials at the end of the RD/DN Note. AUTHORITY: 7 CFR 246.11(e)(4) and (5) WIC Policy Memorandum #2008-4 WIC Nutrition Services Documentation Nutrition Services Standard 14 Value Enhanced Nutrition Assessment (VENA) Guidance RESOURCES: Care Plan Minimum Standards Feb 1, 2022 California WIC Policy and Procedure Manual Page 3 of 3