• Section 9: Academy of Nutrition and Dietetics Medical Nutrition Therapy Documentation

    Defining the Role of the Registered Dietitian and Medical Nutrition Therapy

    The registered dietitian is the healthcare provider with the most intensive experience necessary to provide nutrition services to individuals interested in medical nutrition therapy or preventive nutrition counseling.

    Medical Nutrition Therapy is an essential component of comprehensive healthcare. It is an application of the Nutrition Care Process, a systematic approach to providing high-quality nutrition care in clinical settings that focuses on the management of diseases.30

    Medical Nutrition Therapy (MNT) is defined as a plan or set of steps, developed through a consultative process by a Registered Dietitian, which incorporates current professional knowledge and research, and clearly defines the level, content, and frequency of nutrition care that is appropriate for a disease or condition. Medical nutrition therapy begins with the nutritional assessment of a client, followed by a medically prescribed nutrition therapy based on standard protocols.

    Medical nutrition therapy includes identifying treatment goals and developing the nutrition prescription, providing self-management training through individualized counseling and designing specialized nutrition therapies. During MNT, the registered dietitian provides clients with a comprehensive service that includes an assessment of the nutrition status of a client with a disease, condition, illness or injury that puts the patient at nutritional risk. This nutrition assessment consists of a review and analysis of medical and dietary history, laboratory test values, anthropometric measurements, and food/prescription drug interactions.

    Academy of Nutrition and Dietetics Documentation

    The Academy of Nutrition and Dietetics (AND) has previously noted in their Medical Nutrition Therapy Documentation recommendations that communication among team members is important to provide consistent, quality care. Documentation is one form of communication and is a necessary part of medical care. Documentation is also essential for verifying the quality of care delivered and determining outcomes of care. One of the recommended activities is to document the circumstances and handling of errors.

    The medical record is a legal document that is maintained for communication of care, and includes a description of the care provided and delineation of who provided the care to the client. The government, private insurance companies and healthcare accrediting agencies mandate that the medical record be complete, accurate, and retained for a number of years as stipulated by Medicare or state laws. Reimbursement is also dependent on documentation.

    Evidence Based Guides for Practice

    The RD will find that the AND MNT Evidence Based Guides for Practice (protocols and practice guidelines) provide resources for supporting that the RD meet the following documentation essentials. The dietitian documents the following in the patient's medical record:

    Initial MNT:

      • Receipt of referral, and name of primary dietitian
      • Diagnosis
      • Time and date of the visit
      • Demographic data, measurements
      • Nutrition Assessments -- Nutrition history
      • Baseline data intake
      • Learning needs assessment r/t MNT
      • Clinical and behavioral goals -- Care Plan
      • Interventions -- MNT provided
      • Adherence potential
      • Scheduling of follow-up 

    Follow-up MNT Sessions: 

      • Time and date of the visit
      • Lab data and measurements
      • Progress to goals
      • Adjustments to Care Plan
      • Interventions -- New and reinforcement
      • Barriers and solutions
      • Next Follow-up appointment
      • Appointment failures, and other ways that the patient is not cooperating with the therapeutic plan
      • Follow-up plans

    Dos and Don'ts of Documentation 

    Here are some tips recommended by the Academy of Nutrition and Dietetics to help improve the RD’s charting:

    Do:

      • Check that you have the correct chart before you write.
      • Chart a patient's refusal to allow treatment. Be sure to report this to the patient's physician.
      • Write "late entry" and the date and time if you forgot to document something.
      • Write often enough to tell the whole story.
      • Chart preventive measures.
      • Chart contemporaneously (contemporaneous notes are credible).
      • Write legibly, offering concise, clear notes reflecting facts.
      • Chart what you report to other healthcare providers.
      • Chart solutions as well as problems.
      • Document your observations. Write only what you see, hear, feel, or smell.
      • Encourage others to document relevant information that they share with you.
      • Document circumstances and handling of errors.
      • Chart your efforts to answer your patients' questions.
      • Chart patient/family teaching and response.
      • Chart all referrals/support efforts. 

    Don't: 

      • Chart a verbal order unless you have received one.
      • Chart a symptom (for instance: c/o excessive thirst), without also charting what you did about it.
      • Wait until the end of the day and rely on memory.
      • Ever alter a record. If you make an error, do mark through it with one line, indicate you are making a correction, and initial (or sign) and date.
      • Document what someone else said they heard, saw, or felt (unless the information is critical -- then quote and attribute).
      • Write trivia: "a good day." (What does that mean?)
      • Be imprecise. Avoid terms like "large amounts" and "appears."
      • Write your opinions.
      • Blanket chart or pre-chart. It is considered fraud to chart that you've done something you didn't do.

    It is the position of The Academy of Nutrition and Dietetics that medical nutrition therapy is effective in treating disease and preventing disease complications, resulting in health benefits and cost savings for the public. Therefore, medical nutrition therapy provided by dietetics professionals is an essential reimbursable component of comprehensive healthcare services.

    Section 8. Reducing Medication ErrorsSection 10. State Reporting Requirements