Good charting or documentation promotes resident safety and improves the quality of care.
It’s also necessary for billing and reimbursement purposes under the payment-driven payment model (PDPM), and to prevent surveyors from issuing costly tags or deficiencies.
However, the guidelines for when and what to document can be overwhelming for many dietitians new to long-term care.
Heck, even seasoned long-term care dietitians may question whether they are charting at the right times or including the necessary information in their documentation to prevent nutrition-related tags from surveyors.
This article provides a detailed overview for dietitians working in long-term care on when and what to chart to improve resident care and prevent costly citations from surveyors.
The importance of good documentation
Long-term care facilities that receive payment for Medicare, Medicaid, or both, must follow strict regulations established by the Centers for Medicare and Medicaid (CMS).
When these regulations aren’t followed, long-term care surveyors issue tags or deficiencies, which appear on the statement of deficiencies and plan of correction (CMS 2567) (1).
Some of these tags carry a fine — known as a civic monetary penalty (CMP) — that the long-term care facility must pay for failing to comply with the regulations.
Surveyors commonly issue tags for poor charting practices.
Therefore, it’s important for you to understand when you need to chart and what you should include in your documentation.
Generally, state regulations require that a dietitian complete a nutritional assessment on:
- each new resident upon admission
- any resident having a significant change in diet, eating ability, or nutritional status
- a monthly basis for any resident receiving tube feedings
- an annual basis
You must also chart on residents quarterly unless the dietary manager completes these notes.
However, it’s best to check your state guidelines and the company for which you work to ensure you’re charting when you’re supposed to.
Some states may require discharge notes, but even if they’re not required, it’s good practice to complete them to communicate your nutrition recommendations to the resident or their family and improve the continuum of care.
Admission nutritional assessment
The admission nutritional assessment establishes a baseline and goals for overall nutrition care. It should include whether the resident is malnourished, at risk of malnourishment, or if nutritional status appears adequate.
A validated malnutrition screening tool like the mini-nutritional assessment (MNA) can help you assess malnutrition risk.
Review the resident’s chart, observe and communicate with the resident, and interview key staff members — including family members if necessary — involved in their care.
Use the information and data you gathered to support your determination of their nutritional status.
Complete this assessment within 14 days of their admission.
91 y/o F. Nutrition Status Score: at risk of malnutrition. Resident was admitted on 11/5/22 for therapy and strengthening following hospitalization for hip repair following a fall at home. Resident has a past medical history of T2DM, COPD, HTN, CVD, depression, and breast CA (1997). Medications that affect nutrition and hydration status include atorvastatin (anorexia), citalopram (anorexia, xerostomia), lisinopril (diarrhea, xerostomia), metformin (diarrhea, weight loss), omeprazole (diarrhea, nausea), polyethylene glycol (dehydration), and simvastatin (constipation). Resident is on a regular diet consuming 50-75% at meals. Resident has full dentures, is independent at meals, and reports no issues chewing or swallowing. Resident’s BMI is 27.8, which is appropriate for age and health status. Per resident and family interview, resident’s usual body weight (UBW) is 165 lbs. and resident has not experienced any weight loss or gain x3 mo. Skin is intact; however, the resident is at risk of pressure ulcers due to limited mobility. RD to follow and intervene as indicated.
Quarterly Nutrition Note
The quarterly nutrition note supports minimum data set (MDS) documentation and care plan decisions.
It identifies whether you’re meeting the resident’s care plan goals.
Document how the resident is progressing, if goals are being met, and if any nutrition interventions you have in place are working. Don’t repeat, but summarize all the data you gathered.
See admission nutritional assessment (date) for hx. Resident is at an appropriate BMI for age and health status and maintained her UBW of 165 lbs. Resident is likely meeting nutritional needs with current oral (PO) intakes of 75-100%. Skin remains free of pressure ulcers. Care plan remains relevant. Continue with the plan of care (POC).
Significant change nutrition note
The significant change nutrition note documents change for either improvements or decline of a resident’s status that may affect their nutritional status.
A significant change includes a change in diet or diet texture, weight, eating ability, transition to tube feeding or hospice, and/or a change in health status or medications.
Resident’s diet texture was changed from regular to soft and bite-sized per speech-language pathologist (SLP) evaluation and recommendation related to the resident’s advancing dementia. PO intake prior to texture modification was 25-50%. Weight has trended down since admission (5.6% x2 mo.). RD to follow and monitor changes in PO intakes related to diet texture change. Reviewed and updated POC.
Tube feeding nutrition note
The tube feeding nutrition note is done monthly and must include the nutritional adequacy — including the calories, protein, and fluids — of the feedings.
Review stools, tube feeding tolerance, and recent labs, specifically the electrolytes.
Resident receives an alternate form of nutrition and hydration related to dysphagia secondary to a stroke as recommended by the SLP. Resident receives continuous 12 hr nocturnal feeds of Jevity 1.2 Cal at 135 mL/hr through PEG tube, which provides 1944 kcals, 90 grams PRO, 274 grams CHO, 68 grams FAT, and 1307 mL of free water, providing 135% of the RDI for micronutrients. Resident receives additional 200 mL free water boluses three times per day (TID), bringing total fluid intake to 1907 mL per day. Resident is meeting nutritional needs through current feeding. Labs from 11/05/2022 are within normal limits (WNL). Per the interview with resident and nurse, stool frequency is 1-2 times per day, and the resident is tolerating feeding well.
Annual nutritional assessment
The annual nutrition assessment establishes a new baseline and goals for overall care. It’s similar to the initial nutritional assessment and should follow the same documentation format. Review and update the care plan as necessary.
In-Between Nutrition Note
In-between nutrition notes occur between the required charting times. Instances that warrant an in-between nutrition note include specific observations, referrals, eating changes, wounds, and weight changes that you find relevant.
Resident has experienced significant weight loss of 12 lbs. (7.3% x1 mo.), likely due to inadequate PO intakes averaging 25-50%. Per interview with the nurse, the resident has been eating in her room and refusing several meals. Resident notes her appetite has declined and she has lost interest in social activities. RD notified interdisciplinary team (IDT) of recent weight loss and RD’s interventions of encouraging the resident to dine in the common area, offering an alternative meal if PO intakes are < 50%, and providing high-protein, high-calorie snacks between meals. These interventions will be monitored and evaluated for effectiveness and revised as appropriate.
Discharge Nutrition Note
The discharge nutrition note summarizes a resident’s nutritional status during their stay.
Note any nutrition education needs you may have identified and whether you provided that education prior to discharge.
Update the care plan as necessary for continuation of care.
Resident was admitted on 11/5/22 for strengthening following hospitalization for an intracapsular fracture secondary to a fall. Resident was underweight for age and health status but experienced no significant weight loss during stay and maintained adequate nutrition and hydration status. Resident is set to d/c home on 11/6/22. Provided verbal and written instruction on high-protein, high-calorie foods, and meal ideas prior to d/c.
Summary of nutrition charting guidelines
Here’s a summary of these nutrition charting guidelines for long-term care:
|To establish a baseline and goals for overall nutrition care within 14 days of admission.
|Identify nutritional status and factors that may increase malnutrition risk.
|Supports minimum data set (MDS) documentation and care plan decisions.
|Identify whether the nutrition care plan goals are being met.
|To document changes for either improvements or decline that may affect nutritional status.
|Identify the significant change and how it may affect nutritional status.
|To ensure toleration and nutritional adequacy of tube feeding. Complete monthly.
|Review tube feeding tolerance, labs, and nutritional adequacy.
|To establish a new baseline and goals for overall nutrition care.
|Identify nutritional status and factors that may increase nutrition risk.
|To document changes between the retired charting times.
|Document referrals, wounds, weight, and eating changes.
|To provide a continuity of care and assess educational needs.
|Provide education and update care plan if indicated.
The bottom line
Charting when and what you’re supposed to enhances resident care, supports billing and reimbursement, and prevents costly citations.
In general, you should complete a nutritional assessment for new residents, upon a change in their status, and monthly for residents who receive tube feedings.
You should chart quarterly and upon discharge from the facility.
Use the examples provided for each type of nutrition note to guide how you form your notes for the residents under your care.
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