Connecticut WIC Program Manual

WIC 300-09 SECTION: Nutrition Services

SUBJECT: Nutrition Services Documentation Federal Policy: WIC Nutrition Services Documentation Policy NESF-31-08 See CT Nutrition Services Documentation Guidance. POLICY This policy identifies the purpose, outcomes and necessary elements for documentation of nutrition services in the WIC Program. Nutrition services include:

• Nutrition assessment and risk assignment • Nutrition education/counseling • Breastfeeding support • Food package prescription • Targeted referrals and related follow-up

Quality documentation facilitates the delivery and tracking of meaningful nutrition services and ensures continuity of care for both medically fragile and generally healthy WIC participants. Documentation provides invaluable information for managing and evaluating services delivered. It is also the primary means by which WIC staff communicates within local agencies about individual clients. Documentation is necessary to ensure the:

• Quality of nutrition services provided by identifying nutrition risks and/or participant concerns, facilitating follow-up and continuity of care (help staff follow-up on counseling that occurred during the last agency visit, check on participant’s progress, referral information and/or reinforce nutrition education messages)

• Integrity of the WIC program through documentation of nutrition services data used for eligibility determination (identity, residency, income, category and nutrition risk), WIC Participant and Characteristics reporting and CDC Surveillance Data (PedNSS/PNSS) and appropriate nutrition education contacts are provided to each participant at a rate of a least once per quarter. The elements of quality nutrition services documentation processes must be: • Consistent • Clear • Organized • Complete • Concise

Efficient, meaningful documentation provides a brief synopsis of the participant’s appointment/visit and can be used to facilitate tracking or monitoring of participant’s behavior change over time. At the

local level, quality documentation increases the CPA’s effectiveness in assisting the individual in achieving desired nutrition behaviors.

At the State and Federal level, quality documentation helps organize information, determine if quality WIC nutrition services are provided and give perspective on the effect the program has on participant’s nutrition and lifestyle practices. WIC Program Nutrition Services Documentation Guidance

Please refer to the 2010 WIC Program Nutrition Services Documentation Guidance for more detailed explanation of WIC nutrition services documentation expectations in Connecticut.

Each local agency shall be responsible ensuring that nutrition services are provided and documented in CT-WIC. The expectation is that all client files contain the following:

Contact Type: Certification, re-certification, second nutrition contact, referral follow-up, food package change, or benefit issuance Initials of staff providing the contact Relevant assessment information: Including risks identified through the assessment process, Nutrition Risk screen in CT- WIC. WIC Category and Priority: CT-WIC, Nutrition Risk Screen Food Package Prescribed: Include medical documentation when required and rationale for individual food package tailoring Nutrition Education/Counseling Topic(s): CT-WIC, Nutrition Education Screen(s) high risk including referrals made and follow-up plans.

Local agency staff must establish procedures to ensure that appropriate nutrition education contacts are provided to each participant at a rate of a least once per quarter.

Required information to ensure continuity of care for all participants must include: • Main topics covered in education, especially when multiple risks are identified, CT-WIC, Nutrition Education Screen(s) • Progress toward behavior changes, if goal was set at previous visit, CT-WIC, Nutrition Education Screen(s). • How education was provided, (group, individual) and reinforcements used (i.e. handouts, brochures)

For all individual contacts, use CT-WIC, Update Nutrition Education Screen, to document topics covered in the nutrition education session. Specify what information was discussed since a topic can cover a wide range of issues and participant/CPA concerns. Refer to the CT WIC Program Abbreviation Listing for common abbreviations to be used when completing notes in CT-WIC.

For participants who attend group education sessions, use CT-WIC, Daily Schedule Screen and/or Nutrition Education Screen to document the group contact. A lesson plan for each group should be kept on file at each local agency.

Staff should also document participant refusal or inability to attend or participant in nutrition education. Local agency nutrition staff shall follow up on the status of prior referrals.