West Virginia WIC Policy & Procedure 5.04 Effective Date: 7/9/24 5.04 The Nutrition Care Plan POLICY: An individual Nutrition Care Plan must be completed by the Nutritionist (CPA) or the Nutrition Associate (CPA) for every participant. The Nutrition Care Plan will include the identification of participant concerns, assessment of anthropometric, hematological and nutrition data, rationale for nutrition risks, and participant centered goals specific to risks. PROCEDURE: A. The Nutrition Care Plan 1. The Nutrition Care Plan will be completed by the Nutritionist (CPA) or the Nutrition Associate (CPA) for: a. Initial and subsequent certifications; b. Mid-certification and follow-up appointments, low-risk and high-risk; c. Condition changes; and d. Formula changes. 2. The Nutrition Care Plan will be a brief assessment which identifies participant or parent/guardian concerns, the participant’s anthropometric and hematological data, rationale for nutrition risks, and participant centered goals specific to risks. 3. Documentation will include: (also see Section B.) (C) Client Comments, Follow-up on goals and referrals (A) CPA assessment, Counseling plan (B) A plan or goal for future intervention or behavior change Nutrition Provider Name (First Initial.Last Name) and Title (ex. Nutritionist I) 4. The Nutrition Care Plan will be documented in the Care Plan section of Crossroads. a. Documentation in the Care Plan section will be under Nutrition Assessment for each individual participant. b. The Family Care Plan section will be for the documentation of breastfeeding contacts only. 5. The Nutrition Care Plan must be completed within 24 hours of the date of the visit. a. A Nutrition Care Plan not completed within 24 hours after the date of visit will be considered a missing Nutrition Care Plan. b. A missing Care Plan will warrant a finding during a Management Evaluation and require a corrective action plan. B. Nutrition Care Plan Instruction Page 1 of 5

West Virginia WIC Policy & Procedure 5.04 Effective Date: 7/9/24 5.04 The Nutrition Care Plan 1. (C) Client Comments, Follow-up on goals and referrals: a. This section is to determine the amount of progress being made by participants, if goals are being met and to follow-up on previous goals and referrals. b. Examples of information to include are participant’s (or parent/guardian’s) comments on their well-being, their concerns and/or current status, status of previous goals (barriers or achievements), and/or results of previous referrals. 2. (A) Nutritionist (CPA) or Nutrition Associate (CPA) Assessment, Counseling Plan a. This section should identify the participant’s anthropometric and hematological data, and nutrition concerns and risk. b. Examples of information to include: i. Evaluation of anthropometric measurements, including comparing to past measurements and to the growth chart reference; ii. Evaluation of hemoglobin values; iii. Evaluation of nutrition-related health problems; iv. Evaluation of nutrition-risk codes, including high-risk codes*; v. Evaluation of appropriateness of prescribed diet including adequacy in meeting caloric and nutrient requirements, assessment of participant’s ability to understand and comply with diet; vi. Education plans including diet instructions; vii. Follow-up plan for future clinic visits for evaluation; viii. Referral to other health professionals/agencies. *High-risk codes must be documented in this section 3. (B) A plan or goal for future intervention or behavior change a. The goal(s) should be jointly set with the participant. b. The goal(s) should be specific and achievable. c. An example goal: Participant will increase hemoglobin to normal value by follow-up appointment, by increasing intake of iron-rich and vitamin C-rich food sources. d. If the participant chooses to set a goal, it must be set in the Maintain Goals section. i. The CPA must note “see goals” in the care plan. e. If the participant chooses not to set a goal, it must be documented in the care plan. 4. Nutritionist’s (CPA’s) Signature (First Initial.Last Name) and Title/Credentials. C. Relevant Information to Include in the Nutrition Care Plan Page 2 of 5

West Virginia WIC Policy & Procedure 5.04 Effective Date: 7/9/24 5.04 The Nutrition Care Plan 1. The Nutrition Care Plan information will be relevant to each category and based upon positive health outcomes and adherence to Value Enhanced Nutrition Assessment (VENA). Examples include: a. Pregnant Women: receives ongoing prenatal care, achieves recommended maternal weight gain, remains free from nutrition or foodborne illnesses, avoids certain foods, alcohol, tobacco and illegal drugs, consumes a variety of foods to meet energy and nutrient requirements, and makes an informed decision to breastfeed her infant. b. Breastfeeding Women: receives ongoing postpartum health care, achieves desirable postpartum weight (or BMI), remains free from nutrition or foodborne illnesses, continues to avoid alcohol, tobacco and illegal drugs, consumes a variety of foods to meet energy and nutrient requirements to successfully breastfeed her infant(s). c. Postpartum Women: receives ongoing postpartum health care, achieves desirable postpartum weight (or BMI), remains free from nutrition or foodborne illnesses, continues to avoid alcohol, tobacco and illegal drugs, and consumes a variety of foods to meet energy and nutrient requirements. d. Infants: receives ongoing preventive health care including screenings and immunizations, achieves a normal growth pattern, remains free from nutrition or foodborne illnesses, consumes breast milk and/or iron-fortified infant formula and other foods as developmentally appropriate to meet energy and nutrient requirements and establishes a trusting relationship with parent(s) that contributes to positive feeding experiences. e. Children: receives ongoing preventive health care including screenings and immunizations, achieves a normal growth pattern, remains free from nutrition or foodborne illnesses, consumes a variety of foods to meet energy and nutrient requirements, and achieves developmental milestones including self-feeding D. Nutrition Care Plan Examples 1. See Policy 5.04 Attachment #1 for allowable acronyms and abbreviations. 2. Pregnant: (C) 10 weeks into first pregnancy; states she is eating a variety of foods; concerned prenatal vitamin is making her sick. (A) Adequate weight gain for pre-pregnancy BMI; hgb 10.0, high-risk; discussed iron-rich and vitamin C-rich foods, and recommended taking prenatal vitamins at night/discuss switching vitamins with OB; referral sent to OB for low hgb. (B) Increase hgb value to normal at F/U by increasing iron-rich and vitamin C-rich foods as tolerated. Signature A. Staff, Nutritionist Page 3 of 5

West Virginia WIC Policy & Procedure 5.04 Effective Date: 7/9/24 5.04 The Nutrition Care Plan 3. Breastfeeding Woman: (C) 2 weeks postpartum; states BF is going well, infant eating 2 hrs. on demand; met with BFPC today. (A) Adequate pregnancy weight gain for pre-pregnancy BMI; normal hgb; discussed eating to support energy and nutrient needs; continuing to take prenatal vitamin. (B) Continue breastfeeding for infant’s first year. Signature A. Staff, Nutritionist 4. Postpartum Woman: (C) 2 weeks post c-section; reports decreased appetite. (A) Hgb low 10.8, likely d/t c-section; encouraged eating a variety of foods to support energy needs. (B) No goal set today. Signature A.Staff, Nutritionist 5. Infant: (C) 6-month-old infant; caregiver reports infant is doing well on formula, recently introduced cereal by spoon. (A) Infant gaining weight appropriately – doubled birth weight, normal length; discussed introduction of solids and recommended amounts, and cleaning gums/teeth. (B) See goals. Signature A.Staff, Nutritionist 6. Child: (C) 3-year-old child states he likes to eat fruits and vegetables and likes to drink milk and juice. Child does not like to drink water. (A) Wt/ht above average 75th %tile; normal hgb; discussed adding water to juice; encouraged more water, less juice/sugar-sweetened beverages; referral sent to Head Start. (B) Caregiver will add water to juice to decrease intake of sugar sweetened beverages, will f/u on progress at next certification appointment. Signature A.Staff, Nutritionist 7. Condition Change: (example: Fully BF woman to non-breastfeeding) (C) Mother reports infant has weaned; requests full-formula package of Similac Sensitive. (A) Discussed formula preparations. (B) Mother will continue feeding infant Similac Sensitive. Signature A.Staff, Nutritionist 8. Formula Change: (C) Caregiver reports infant is vomiting on current formula; received WIC-53 for Nutramigen. (A) Discussed mixing formula correctly and hunger cues. Page 4 of 5

West Virginia WIC Policy & Procedure 5.04 Effective Date: 7/9/24 5.04 The Nutrition Care Plan (B) Formula changed to Nutramigen; handout given for formula transition. Signature A.Staff, Nutritionist ATTACHMENTS: Allowable Acronyms and Abbreviations REFERENCES: 1. CFR 246.11, WIC Regulations, Nutrition Education 2. USDA WIC Nutrition Services Standards, Standard 14, Documentation Page 5 of 5