Writing a nutrition assessment summary is one of the essential skills you’ll use every day as a clinical dietitian. Start here to learn how to write really good ones, fast.
How to Write a Nutrition Assessment Summary
A nutrition assessment summary is where everything important about your patient comes together for quick reference.
No matter if you choose to use bullet points or complete sentences. This is one of the most important parts of your notes.
In this post, we’re going to go over:
- Why you need to know how to write an assessment summary
- Easy ways to write a nutrition assessment summary well
- Things to pay attention to when you’re writing the summary section of your nutrition assessment
Let’s start at the beginning and quickly talk about why we’re doing this in the first place.
It's Not Just You
Trying to figure out how to write nutrition assessments and summaries that will make your preceptors proud is hard.
Really hard.
And it’s SO MUCH harder when you’re trying to learn it at the same time you’re trying to learn everything else.
When you’re starting your internship, you’re never just doing and learning one thing at a time.
You’re learning EVERYTHING. At the same time.
You’re navigating a new environment.
And learning a new EMR system.
Meeting new people and trying to remember names.
You’re trying to be friendly and smart and organized.
And that’s just Day 1.
You’re also seeing patients for the first time.
Which means you’re also starting to document on those patients, AND are expected to get so good at all of this in a few weeks that you can do it at lightning speed.
Let’s start by saying every facility you work in will have a slightly different template they use for nutrition assessments based on the EMR system they have in place.
This will directly impact things like:
- Where you’ll enter certain information
- If you use fill-in-the-blank boxes, click-box options, or drop down menus
- The way specific information is presented
What you’ll get here isn’t an exact replica of the EMR template your facility will use. Here, we’re taking about
The documentation you do for each patient you see will determine a few things:
- How fast you can see patients, which means it will determine if you can meet your internship’s requirements during staff relief.
- How well you can pull relevant information from the medical chart, which will be detailed in the assessment template you fill in AND the assessment summary you can free-write.
- How much you understand what the nutritional issues are and what you should do about them, which you’ll identify in your notes.
If you’re not able to do each one of these things, without question you’re going to have preceptors who will need you to learn them.
You must be able to move quickly when reviewing patient care information and doing in-person evaluations.
You’ve got to be able to figure out what’s important and what’s not, then be able to organize and prioritize it all.
You’ve got to be able to take all the information you’ve pulled together and then create a summary that your preceptors will recognize as valuable.
It’s a lot on your plate. And it’s not easy.
So let’s talk about what you need to know how to do…and how to get that done.
Rather just get a full set of downloads so you can start writing better assessments, faster? The Clinical Evaluation Power Pack has everything you need to get started right now.
Why you need to know how to write a nutrition assessment summary
The short answer is because it is ESSENTIAL to completing the documentation part of working as a clinical dietitian.
Which is exactly what you’ll be doing in your clinical rotations.
You know you’re supposed to know how to do the science part of clinical nutrition. Medical nutrition therapy is supposed to be the who point of being a clinical dietitian.
And it is. Mostly.
You cannot get through your clinical rotations without knowing your MNT basics.
You also CANNOT get through your clinical rotations without knowing how to chart on patients.
And because this isn’t taught – there’s no class on how to write amazing nutrition assessment summaries – most dietetic interns start their clinical rotations without any understanding of how to do the documentation side of clinical.
Unfortunately, knowing all the MNT in the world means almost nothing if you can’t put that information into the document format that your facility is looking for.
But most specifically, the format that your each of your preceptors will approve of.
Before we dive into each of these, you’ve got to remember one more frustrating thing:
Every facility you work in will have a slightly different template they use for nutrition assessments based on the EMR system they have in place.
This will directly impact things like:
- Where you’ll enter certain information
- If you use fill-in-the-blank boxes, click-box options, or drop down menus
- The way specific information is presented
And as you feel more comfortable with the documentation you do, you’ll start to see changes in:
- How fast you can see patients, which means it will determine if you can meet your internship’s requirements during staff relief.
- How well you can pull relevant information from the medical chart, which will be detailed in the assessment template you fill in AND the assessment summary you can free-write.
- How much you understand what the nutritional issues are and what you should do about them, which you’ll identify in your notes.
If you’re not able to do each one of these things, without question you’re going to have preceptors who will need you to learn them.
But we aren’t here to look at specific EMR nutrition assessment templates.
We’re here to help you get moving faster and more efficienctly, so you can use the assessment summary to your advantage and be able to:
- Move quickly when reviewing patient care information and doing in-person evaluations.
- Figure out what’s important and what’s not, then be able to organize and prioritize it all.
- Correctly compile all that information and to write a complete summary that your preceptor will love.
So, let’s get to it.
What exactly is the Nutrition Assessment Summary?
The nutrition assessment summary is the last part of each nutrition assessment, and are part of every template for new admissions and follow-ups, as well as quarterlies and annuals (if you’re in LTC).
This is where you can write whatever you want, in any kind of format you like.
The nutrition assessment summary is as important as you decide it is.
By the time you get to the summary section, you’ll have already entered all the most important information into the assessment template.
The summary section is your chance to explain, expand, or reinforce anything you want to be able to quickly reference without reviewing the entire assessment for a single detail or fact.
It’s also an opportunity to pull together everything relevant in a single spot.
Every dietitian (which also means every preceptor) uses this space a little differently.
PRO TIP: There’s no right or wrong way to complete the assessment summary. And when you’re an RD, you can fill it out in any way you want.
But it does tend to be quite personal to the RD completing the assessment. So until then, the best advice to to follow your preceptor’s lead.
We’ll talk a lot more about that soon.
4 key parts to the nutrition assessment summary
There are 4 things you need to be able to do, in order to write a great nutrition assessment summary.
And learning to chart is always easier when you have a step-by-step guide.
Remember when talked about how every RD does their job just a little bit differently from each other?
Yea…that makes it really easy to quickly feel overwhelmed by what one preceptor says to do and what another tells you is a waste of time.
So let’s talk about the 4 things you need to be able to do:
- Know what to pay attention to in an EMR, and what you can ignore
- Combine what you learn from the chart with what you learn from your patient
- Write your notes and the assessment summary
- Use your preceptor’s language
Master these, and you’ll be THAT intern who always knows exactly how to handle everything that comes up.
How to complete each part of the nutrition assessment summary:
First: What to focus on in an EMR
The short answer is only what you need to know to complete the assessment.
The long answer is you’ve got to first decide what the most acute nutritional issue is. Then run that down through every key aspect of the medical chart including:
- Pertinent labs
- Relevant meds
- Current vs usual weight status, with a sprinkle of ideal reference in there
- Diet needs
- Any ongoing, recent, or anticipated medical changes
What you don’t have to linger over are nursing notes that document a patient’s daily vitals or MedPass confirmations.
Get the Clinical Evaluation Power Pack for a complete bundle that includes what to focus on and what you can ignore.
Second: Adding to your EMR notes with patient answers
Going to see your patient, especially when they’re a new admit, is non-negotiable.
Maybe you can’t speak to them because they’re intubated.
Maybe they don’t want anything to do with you and ignore you the second you enter their room.
It doesn’t matter.
The minute you lay eyes on your patients, you’re able to gather information that you’re not likely to find in their chart.
That might mean you can (or can’t) do a nutrition-focused physical exam. The answer to that goes in your note.
You might have a fantastic 4-minute conversation with them and learn exactly why they’re eating so much salt despite their CHF, their edema, and the cellulitis you noticed when you walked into the room.
That goes in your note also.
Having that first conversation with your patient doesn’t have to take hours.
Think of it like a fact-finding mission.
An opportunity to fill in some of the blanks you’ve discovered in the chart and make sure your final evaluation answers as many questions about your patient’s overall nutritional status as possible.
Things like:
- What your patient’s UBW is and how much they think it’s changed over the last 6 months or year
- If their CBW matches what you find in their physical or if they seem to have higher / lower risk for malnutrition (and what that’s based on)
- How much they’re really eating vs. how much the chart says they’re eating
- What they’re willing to eat and if they’re actually enjoying the ONS someone added
Need something to keep you focused on what’s most important in your assessments? The Clinical Evaluation Power Pack will keep you organized and focused.
Third: Writing the nutrition assessment summary
When you’re handed that first patient and told to “do their assessment”, where do you start?
The best thing you can do when you’re writing nutrition assessments for the first time is to be prepared.
If you’ve collected all the information from the EMR that we talked about, and have a set of notes from when you talked to your patient, you’re ready to write your note.
But what about the nutrition assessment summary?
That intimidating, blank comment box at the end of the assessment template.
What goes into the assessment summary is a personal decision, and you’ll see every one of your preceptors write it in a slightly different way.
Some will keep it very simple and only include:
- A bulleted list of what they’re going to monitor.
- And another bulleted list of what interventions they’ll be using.
Others will write out their patient’s goals. What they’ll be monitoring. And how they’ll be following up in a couple of very short sentences.
And then you’ll see other RDs use the box to summarize all or some of the information in the template in a few short sentences.
They’ll include all the information they consider relevant. And make sure it’s all easily accessible in one place, instead of having to scroll through a 7-page assessment.
Ultimately, it’s going to be your decision how you use that summary box when you’re an RD.
But if you’re stuck and you don’t know where to start, here’s a simple and very complete structure to follow for writing your nutrition assessment summary.
- The most acute nutritional issue (or whatever you’re intervention is based on)
- Any pertinent labs or medications relevant to their issue you’re focused on
- Detailing any wounds
- Weight status, diet order, and how they might be related
- Goals, interventions, and monitoring objectives
This can be written out in complete sentences, bullet points, or a combination of both. You can add or subtract any amount of information to this shortlist.
As long as you’re completing the nutrition assessment template found in your facility’s EMR, you can write your assessment in your own way.
Need a detailed set of instructions on what actual sentences can look like in an assessment summary? The Clinical Evaluation Power Pack has mix-and-match phrases, along with a complete set of examples you can cut and paste to make life easier and writing a lot faster.
Fourth: Using your preceptor’s language
So now you know what to look for in an EMR.
You know what you’re going to find out from your patients when you visit them.
And you know have a solid format to follow when it’s time to write your nutrition assessment summary.
The final part of writing the assessment summary is just plain good advice for your dietetic internship.
As an intern, the best practice is to follow your preceptor’s lead.
If your preceptor likes to keep the summary box short and simple, then you keep the information you put in the summary section nice and short.
If your preceptor tends to lean more towards full nutrition summaries, that’s your cue to get more comprehensive.
Remember that as an intern, you’re charting under someone else’s credentials.
It makes sense that they would be extremely particular with the language and phrasing you use in your notes.
True, it can make life pretty frustrating.
One preceptor will insist on you include certain items that another will consider completely irrelevant.
This isn’t you not being smart enough.
It’s about different RDs having different preferences. And that’s it.
Make your life easier by reading one of their past assessments and using the exact same language refreshed for your new patient.
If your preceptor likes listing out every single medication a patient is on and detailing the nutritional implications of every last one — then you do that too.
And if your next preceptor insists you only mention the “important ones”, then it’s time to switch it up.
No, this has nothing to do with learning nutrition.
Yes, you have to be able to do this no matter how annoying it is.
Maybe you have amazing preceptors who are patient and encourage you to develop your own voice.
That’s the dream, honey! You’ve won the internship jackpot.
But for the rest of you, you’re still going to have to write assessment summaries.
And you’re going to be evaluated on how well they match the voice and tone of the preceptor you’re charting under.
The best thing you can do for yourself is follow their lead. Give them what they want. And ask as many questions as you can fit into a day.
And That’s It!
Now you should have a really good sense about what to pay attention to in an EMR, and what you can ignore, how to combine what you learn from the chart with what you learn from your patient, what to include in your notes and the assessment summary, and why you’ve GOT to use your preceptor’s language
Looking for more posts about about how you can kill it in your internship? Check these out:
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