Creating a therapeutic diet order can be tricky. Specifically, how to write really clear diet orders for complex patients. This article shows you exactly what you need to focus on, so every diet order you write is flawless.
5 steps to the perfect therapeutic diet order
I remember when I first got to my (very clinical heavy) dietetic internship. It took about 4 minutes for me to realize that I was completely unprepared to write diet orders that actually made sense. And if I’m being really honest, I didn’t get really good at it until I started finished my DI and started working as an RD in acute care.
Part of the difficulty I had was with preceptors who weren’t very helpful. A bigger part was that I really struggled with the confidence to recognize where I was lacking and get specific help to get better. Because of this, I made a lot of mistakes.
This guide gives you what I never had: a chance to get great at writing diet orders fast.
Instead of struggling through trial-by-error, you’re going to get the 5 simple steps that will make sure your diet orders are always clear and complete.
These are the 5 steps to crafting a perfect diet order:
- Identify the medical diagnoses
- Evaluate SLP needs
- Verify skin integrity
- Determine weight status
- Put it all together
This works if you’re in an acute setting, a long-term care dietitian or are starting with outpatient counseling.
Following these steps will make sure you end up with a diet order that reflects ALL the nutritional needs of your patient. Each of these steps take you through key information crucial to determining the overall nutritional status of your patient.
What makes diet orders for complex patients so hard?
Here’s a hint: it’s not.
At the heart of it, the process of writing a diet order for a complex patient is exactly the same process as writing it for patient with more straightforward diagnosis.
With a clear step by step process, you’ll can be sure that you’ve reviewed everything important could possibly change the final diet order. And ultimately, your patient’s nutrition care plan.
For example, let’s say you have a patient admitted to the ICU for acute kidney failure. But they also have a history of diabetes along with some heart conditions. Where do you start?
You start by figuring out what’s most important, what’s missing and how to pull it all together.
Want something a little more hands on? 👉 Check out the Diet Order Quick Course. You’ll be in and out in about an hour with handouts, videos and case studies to take all this info to the next level. Get started HERE.
1. Medical diagnoses
Before you even start writing the diet order, you’ve got to be comfortable reading your patient’s medical chart.
At this point, most facilities are using an EMR system (electronic medical record). These make it pretty easy to click around to explore your patient’s current medical conditions. You’ll be able to see your patient’s diagnoses, get a look at their previous admissions and if they’re scheduled for any specialist workups.
For facilities still transitioning out of paper charts, flip through them for a while. Get a feel for how the notes are set up in patient books. Make sure you’re clear on where to look for notes that haven’t yet been filed into the book. Knowing this up front can save you a lot of time and headaches down the road. Just because everything you need should be in that chart, doesn’t mean it will be.
So the faster you’re able to review the information you’ve got available to you, the quicker you’ll know what else you need.
Part 1: Determine the reason for admission
Think about two people who were recently admitted to the hospital.
- A patient admitted for a car accident and happened to have had a stroke 6 years ago.
- A patient admitted for a stroke.
Both have had a stroke. However, each patient will need a very different kind of attention.
These are examples of an admitting diagnosis that will define almost all treatment your patient encounters during their stay at your facility. It will also be the starting point for every medical nutrition therapy decision you will make for them, as you determine their dietary needs.
Part 2: Chart Review
After you identify the reason your patient’s admission, it’s time to review their chart. Here you’re looking for other nutritionally relevant diagnoses that will change the kind of therapeutic diet your patient needs.
Think:
- DM (diabetes)
- CHF (congestive heart failure)
- Cholecystectomy (gallbladder removal)
- Cancer
- Heart attack
Be clear about the MEDICAL diagnoses that won’t need a therapeutic diet order. Things like a sprained ankle or surgery for a gunshot to the shoulder will usually mean a regular diet order and can be left off the diet order.
Take note of the issues that are nutritionally relevant. Then move on to step 2.
2. SLP needs
Next up, swallowing. Does your patient need a Speech and Language Pathologist consult? Think about this question with every patient you have.
When it comes to swallowing issues, there are always huge red flags that pop up when you read a chart. Like our patient who was admitted for a stroke. Or someone who was just extubated.
However, keep in mind that there are lot of other issues that can also put someone at increased risk for aspiration. And many of these can be much more subtle.
Think:
- Dental issues
- Missing or badly fitting dentures
- Throat cancer
- Even breathing issues
All potential swallowing issues that pop up on your radar should be addressed in your diet order. And each one should have an SLP consultation requested by a doctor.
100% of the time. Even if you have to push a doctor hard for to get one.
Remember: it’s always better to be the one who first identifies a swallowing issue, instead of the one who overlooks a potential problem.
Add your patient’s swallowing issues to the list, and let’s keep going.
3. Skin integrity
Third up, wounds. This one is sometimes taken for granted. Why? Because it’s so easy to ASSUME it will be documented in the patient’s chart.
Don’t assume this.
SKIN INTEGRITY IS NOT ALWAYS DOCUMENTED IN THE CHART.
Highlight that sentence. And then memorize it.
If there’s the slightest concern there could be a pressure ulcer or other non-healing wounds, you want to know about it. Immediately.
Think:
- Bed bound patients or those with poor mobility
- Patients who have histories of decubitus ulcers
- People with malnutrition concerns
- Long-term ICU patients. Just to name a few.
Every one of them should have been evaluated for wounds on admission. Which means it should have already been documented by the time you receive the nutrition referral.
If you’re still not sure if they have wounds, you MUST ask and get a clear answer. First ask your patient (if they’re able to speak) — they know if they have pain or wounds. Then follow up with their nurse and confirm their answer. You want to be the first to document a pressure ulcer and not the one who missed it.
As with any skin integrity issues, the therapeutic diet order will reflect your patient’s increased needs. The diet order and patient note you then write will both state one of two things:
- Your patient’s skin is intact.
- What type of wound they have and how you plan to address their increased needs.
If there are wounds, make sure your diet order clearly indicates those nutritional needs.
Quick Note About Diet Orders and Pressure Ulcers
There will probably be times when you realize that your patient’s nutritional needs conflict with their most acute diagnosis. This is where your professional judgment comes in.
It’s also where you take exceptional care to DOCUMENT every. single. decision. you’ve decided to make.
Make note of your patient’s skin status and then move to step 4.
4. Weight status
Spend any amount of time in clinical nutrition and you’ll very quickly learn that getting a patient’s weight can be one of the world’s MOST frustrating experiences.
People doing the intake forget about report it. Bed scales don’t work. Patients aren’t able to stand on scales. Patients don’t know how much they weigh. The list goes on. This obviously makes figuring out a therapeutic diet order that much more difficult.
When you do your chart review, check for your patient’s anthropometrics (ie: their height and weight). If it’s there, it’s a good day. It’s not there and you’ve got to dig for it.
Without that information, determining an appropriate therapeutic diet may become very difficult.
Think:
- Significant weight changes
- Over or under nutrition
- Metabolic concerns
- Evaluating calorie counts or setting enteral feeds based on accurate estimated nutritional needs.
Whatever you find, write it down. And then get ready to put it all together.
5. Write the diet order
Finally, the fun part. You now have everything you need to create a perfect therapeutic diet order. All that’s left is to put it all together.
Use the list you just created and assemble into a running list.
Think:
- Mechanical soft
- Low salt, diabetic diet
- Renal, puree diet with nectar thick liquids
- Clear liquids with 15g protein supplement TID
Make sure every nutritionally relevant diagnosis is represented. And don’t forget to include in the diet order any consistency downgrades. Even if you’re still waiting for a SLP evaluation.
Remember: a diet order can be as long as you need it to be. Include everything important. Length doesn’t matter.
Give yourself a little time to get the hang of this. The more time we spend in a clinical environment, the easier writing therapeutic diet orders becomes. These steps will become second nature the more you do them.
Give yourself a little time to get the hang of all of this. The more time we spend in a clinical environment, the easier writing therapeutic diet orders becomes. These steps will become second nature the more you do them.
And suddenly, one day, you’ll be writing diet in your sleep.
And That’s It!
Want something a little more hands on?
Check out the Diet Order Quick Course. You’ll be in and out in about an hour with handouts, videos and case studies to take all this info to the next level. Get started here.
Want even more to help in clinical?
Check out The Nutrition Cheat Sheets Shop for all the nutrition education and clinical resources that will make your life easier.
