Do you know if your clinical nutrition documentation is good enough? Start here for a clear guide on what you should be doing and how to get it done.
How do you know if your clinical nutrition documentation is good enough?
Let’s start with the short answer.
The simple answer is you’ve included all the relevant and important pieces of information in the note you’re writing.
It’s really that simple.
If all the important things about your patient’s nutritional status are included in your nutrition notes, you’re 75% of the way there.
Now here’s the complete answer:
You have included all relevant pieces of information AND you’ve justified every single recommendation you’ve made.
This means you haven’t only said what’s happening and what you want to do about it…
You’ve also been extremely clear with the whys.
Why you consider something important and why you’re doing that thing you’ve decided to do.
Justifying your recommendations is the last 25% of writing your note. And maybe the most important part of everything you do.
When your charting includes all of this, you know you’ve written a great clinical nutrition note.
Piece of cake, right? Ha.
If it sounds so simple…
Why is this so hard?
There are three answers to this question:
- Dietitians are notoriously attached to the style in which they write their notes
- School-answers can be really different from real-life-answers
- Every RD has a slightly different way of doing clinical (we’re talking about preceptors!)
RDs can be very attached to the layouts and language they use in the notes they write.
Which means as you’re bouncing between preceptors in a single clinical rotation, it can be extra tough to figure out the “right” way to do things.
Especially when every preceptor you have is telling you they want something different.
Things can get even harder when some of the answers drilled into your head in school, are suddenly thrown into question in complex patient care scenarios.
Rarely in clinical nutrition are things simple and straightforward. There’s always the chance that a single new piece of information can suddenly change an entire obvious diet plan.
And to make matters worse, clinical nutrition is all about acceptable ranges.
Which means every RD has the potential to have a slightly different opinion about what the “correct” clinical intervention answer is.
Nutrition was hard when you were in school.
Now you’ve got to deal with all this…
It can feel like an impossible ask to write notes that are going to be good enough.
How can you make sure your notes are always good enough?
As impossible as it feels, it’s not an impossible task.
The goal is to make sure that even if your preceptor wants to rephrase something, tells you your layout is all wrong, or even wants to do something totally different, the content of your nutrition notes will always be clear and compelling.
Here are the two things you’re going to do every single time you write a clinical nutrition note.
First, make sure ALL relevant information is included in the note.
Most clinical nutrition documentation is going to be easy to follow templates.
These are usually a fill-in-the-blank and a box-click situation. Pretty straight forward without a lot of tricks or surprises.
And as long as you’ve collected all the relevant information that goes in the template, all you’ll have to do is put it into its assigned box.
There’s not a lot to mess up with this one.
The harder question is where do you find that information and how do you know if you’re missing anything?
Great question.
These are the five primary places you’ll find all the information you’ll use in a nutrition assessment:
- Medical diagnoses list or the past medical history
- Labs
- Medications
- Relevant medical notes in the medical chart
- Patient interview responses
- Now you’ve got that information, what are you going to do with it?
Another great question.
Generally, you’re going to need to have answers about:
- Weight status
- How they’ll be fed and what the recommended diet order is
- Relevant medical conditions, labs, medications
- Skin integrity and edema status
- Anything additional that might compromise or alter a patient’s nutritional status
- If you can start with all of this information on hand, writing your nutrition assessment will be way easier.
Second, justify every statement and recommendation you make. Every single one.
Every time you make a statement you should include:
- Why something is true (ie: Altered renal labs likely 2/2 CKD stage 3)
- How you know it’s true (ie: Wound healed with skin now intact per RN 5/17 note)
- Why it’s important (ie: Recommend Suplena TID with ongoing inadequate intake <25%, CKD, and malnutrition dx)
- Each intervention and monitoring statement you include in your notes should have a clear justification or reference made in your documentation.
Never assume your reader knows what you’re talking about.
Don’t assume they can find a piece of information tucked into that short note you miraculously stumbled across.
Write every note as though your reader has no idea who your patient is or what’s going on with them. Reference everything, even if that’s your own note (ie: see RD 4/29 eval for details).
This is how you’ll make sure to have complete nutrition assessments every time.
Looking for help structuring and writing your nutrition assessment summaries? Click here to check out the Clinical Evaluation Power Pack and get everything you need to write perfect notes, fast.
Two more useful tips when charting your clinical nutrition documentation
PES statements and the assessment summary are two more places to practice making sure your notes are always fantastic.
#1: Justifying your argument and writing great PES statements
PES statements teach you how to justify your argument.
They force you to be able to say what’s the most important thing going on with your patient, and why that issue is so acute.
Happily, not every facility requires formal PES statements in their clinical nutrition documentation.
But that shouldn’t stop you from rephrasing them into simple language so you can:
- Use them as great starting points when you’re trying to figure out what the most acute issue is (the problem = P)
- State why that thing is so important to manage (the etiology = E)
- Identify what you’re going to do about it (the solution, formally used to ID the symptoms = S)
Looking for some extra help writing PES statements? Check out the post: PES Statements for New RDs and then check out the PES handout in this resource pack
#2: Writing the Assessment Summary
The assessment summary is the most personal part of all the clinical nutrition documentation items you’ll be putting together.
Everyone writes it a little differently.
Some folks keep it super simple with just the highlights.
Other dietitians use it as a chance to pull key parts of their assessment or follow-up together so all the important information they want to reference is in one place and laid out in an easy-to-read format.
What’s the right way?
It’s completely up to you.
There’s no wrong answer, even if a preceptor tells you differently.
When you’re an RD, you can write this any way you want.
But like the PES statement, this part of clinical nutrition documentation can take a little practice – and little savvy.
Even though the concept is generally straightforward, it can be easy to lose track of what to include, how much to say, and how to phrase it.
Some RDs like to be very thorough and use the assessment summary as a chance to consolidate all the information from a usually long and badly laid out nutrition assessment template.
Other dietitians keep it much more concise and only include interventions and monitoring objectives.
The decision is yours.
…unless you’re charting for your preceptor.
In which case, just do it the way they like it done. And then change, make sure to adjust when you change preceptors.
And that’s it for your clinical nutrition documentation!
These tips will make sure your clinical nutrition documentation is good enough every time you chart.
Looking for some more tips on writing assessments?
Check out these blog posts:
- How to Write a Nutritional Assessment: A complete guide
- 3 Nutrition Assessment Writing Tips
- Clinical Nutrition Resources: Toolkit for New RDs
And to get clear on writing the nutrition assessment summary, grab the Clinical Evaluation Power Pack to make every assessment faster and easier.
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.
