1: NCP, Documentation, and Nutrient Needs

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Questions and Answers

What does the 'S' in SOAP notes represent?

Statistical data related to treatment outcomes

Sensory information gathered from the patient's environment

Summary of medical history and current medications

Subjective information obtained during verbal interviews (correct)

Which component of the SOAP notes encompasses data such as medical diagnoses and lab results?

Monitoring

Plan

Objective (correct)

Assessment

What is included in the 'A' or Assessment of SOAP?

Chief complaints and current diet order.

Interpretation of nutritional status and risk level. (correct)

Recommended actions for nutritional care.

Subjective complaints from the patient.

In the context of SOAP notes, what does the 'P' stand for?

Plan of recommended actions for nutritional care Signup and view all the answers

Which piece of information is NOT included in the assessment phase of SOAP notes?

Observations of the patient's weight and height Signup and view all the answers

What should be used to estimate energy requirements for critically ill obese patients when indirect calorimetry is unavailable?

Penn State University 2010 predictive equation Signup and view all the answers

For hospitalized obese patients, what is the energy requirement estimation method if indirect calorimetry is not available and Penn State equations cannot be used?

Mifflin-St Jeor equation using actual body weight Signup and view all the answers

Which of the following is the estimated energy need for critically ill patients classified with a BMI greater than 30?

11-14 kcal/kg actual body weight Signup and view all the answers

What is the protein requirement for patients with renal disease on hemodialysis?

<blockquote> 1.2-1.5 g/kg </blockquote> Signup and view all the answers

Which condition requires a protein intake of 1.5-2 g/kg and indicates a state of increased metabolic stress?

Critical illness Signup and view all the answers

For which patient group is an estimated protein requirement of 1.5 g/kg advised if there is sufficient organ function?

Metabolically stressed patients Signup and view all the answers

What is the estimated protein requirement for patients undergoing a bone marrow transplant?

1.5 g/kg Signup and view all the answers

Which factor contributes to increased fluid requirements in patients?

Increased body temperature Signup and view all the answers

Which condition requires additional protein intake of +25 g/d during specific pregnancy trimesters?

Normal pregnancy Signup and view all the answers

What is the typical range of fluid intake based on body weight for normal maintenance?

25-30 mL/kg Signup and view all the answers

In patients with a pressure injury, what is the estimated calorie requirement?

30-35 kcal/kg Signup and view all the answers

What minimum protein requirement is suggested for adults who are maintaining their health?

0.8 g/kg Signup and view all the answers

Which of the following conditions involves a protein requirement of 1.25-1.5 g/kg?

Pulmonary disease Signup and view all the answers

What factor is NOT typically considered when determining fluid requirements?

Protein intake Signup and view all the answers

What is the primary purpose of nutrition screening?

To identify individuals at nutritional risk and determine the need for further assessment Signup and view all the answers

Who is responsible for completing nutrition screenings?

Registered nurses (RNs) and other healthcare professionals Signup and view all the answers

Which step follows the Nutrition Assessment in the Nutrition Care Process?

Nutrition Diagnosis Signup and view all the answers

Which of the following is a feature of effective screening tools?

Quick, inexpensive and low risk to individuals Signup and view all the answers

What does the term 'validity' refer to in the context of screening tools?

The tool's accuracy in measuring what it is designed to measure Signup and view all the answers

Which screening tool is specifically meant for identifying patients at risk of malnutrition?

Malnutrition Universal Screening Tool (MUST) Signup and view all the answers

What is the role of the Nutrition Intervention step in the Nutrition Care Process?

To implement nutrition plans targeting the cause of nutritional problems Signup and view all the answers

What is assessed by the sensitivity of a nutrition screening tool?

The percentage of at-risk individuals correctly identified by the tool Signup and view all the answers

During which step is monitoring and evaluation conducted?

Nutrition Intervention Signup and view all the answers

Which of the following is NOT a characteristic of a reliable screening tool?

Provides varied results on repeated measures Signup and view all the answers

What key aspect is evaluated when using specificity in screening tools?

Correctly identifying well-nourished individuals Signup and view all the answers

Which of the following tools is designed to assess overall nutrition status rather than just screening?

Mini Nutrition Assessment (MNA) Short Form Signup and view all the answers

Which of the following steps is often revisited if a patient does not make progress?

Nutrition Intervention Signup and view all the answers

What is a critical factor in determining if a tool is both valid and reliable?

Consistency in measuring the same variable Signup and view all the answers

What is the initial focus of the Nutrition Care Process?

Nutrition Assessment Signup and view all the answers

What is the primary focus of Title I of HIPAA?

Protection of health insurance coverage for workers Signup and view all the answers

Which provision addresses the security and privacy of health data under HIPAA?

Title II Signup and view all the answers

What is included in the Admission Record of a medical record?

Reason for admission Signup and view all the answers

What must be included in medical record entries according to best practices?

All entries signed with credentials Signup and view all the answers

Who is authorized to write orders within their scope of practice?

Non-physician licensed professionals Signup and view all the answers

Which documentation style involves assessment, diagnosis, intervention, monitoring, and evaluation?

ADIME Signup and view all the answers

What is one of the purposes of the Administrative Simplification provisions of HIPAA?

To establish national standards for electronic health transactions Signup and view all the answers

What type of information is typically found in the Clinical Record section of a medical record?

Current medical issues and history Signup and view all the answers

Why should healthcare professionals avoid using unclear abbreviations in medical records?

To prevent miscommunication and errors Signup and view all the answers

Which format is NOT recognized as a documentation style listed in the content?

DORS Signup and view all the answers

What kind of orders can non-physician licensed professionals write?

Diet and nutritional plans Signup and view all the answers

What is the purpose of progress notes in a medical record?

To report clinical changes and new information Signup and view all the answers

Which of the following is a recommended practice in writing orders?

Orders must be dictated by state law and policy Signup and view all the answers

What is typically included in the Discharge Note of a medical record?

Discharge diagnoses Signup and view all the answers

What is the primary goal of identifying and implementing appropriate MNT strategies?

To ensure individualized, effective nutritional therapy Signup and view all the answers

Which type of data is NOT typically included in the initial assessment for nutrition therapy?

Personal hobbies and interests Signup and view all the answers

How is percent ideal body weight (%IBW) calculated?

%IBW = Actual weight / Ideal body weight x 100 Signup and view all the answers

Which component is included in anthropometric data collection?

Height and weight measurements Signup and view all the answers

What does a nutritional history assessment typically include?

Usual eating patterns and dietary restrictions Signup and view all the answers

What is the formula used to calculate percent weight change?

%wt change = (Usual weight - Actual weight) / Usual weight x 100 Signup and view all the answers

Which factor is considered when estimating Ideal Body Weight (IBW) for males?

106# for the first 5ft + 6# for each additional inch Signup and view all the answers

Which demographic information is important to document in a medical record?

Current chief complaints and symptoms Signup and view all the answers

What type of data is collected during the nutrition-focused physical examination?

Clinical signs and symptoms related to nutrition Signup and view all the answers

Which aspect is included in collecting a comprehensive client history for nutritional assessment?

Occupation and activity patterns Signup and view all the answers

What is an example of how to adjust Ideal Body Weight estimation for wasted limb situations?

Subtract the respective percentage from IBW based on the missing limb Signup and view all the answers

What must be documented according to compliance requirements?

All aspects of patient care must be documented Signup and view all the answers

Which statement best describes the role of HIPAA in medical record documentation?

It ensures that patient data confidentiality is maintained Signup and view all the answers

In assessing food and nutrition history, which of the following is critical for understanding dietary habits?

Food allergies and intolerances Signup and view all the answers

Which of these is NOT a method used for dietary intake analysis?

Medical imaging analysis Signup and view all the answers

Study Notes

Energy Requirements for Obese Patients

When indirect calorimetry is unavailable for critically ill obese patients, the Penn State University 2010 predictive equation should be used.
If the patient is over 60 years old, the modified Penn State University equation should be used.
For hospitalized obese patients where indirect calorimetry is unavailable and the Penn State University equations cannot be used, the Mifflin-St Jeor equation using actual body weight can be used.

Energy Requirements for Various Patient Types

Healthy Adult, Ambulatory: 25-30kcal/kg
Healthy Adult, Active: 30-35kcal/kg
Overweight: 21-25kcal/kg
Obese: 18-21kcal/kg
Critically Ill, intubated: 25-30kcal/kg
Critically ill (BMI >30): 11-14kcal/kg actual body weight
Pressure Injury: 30-35kcal/kg

Energy Requirements for Specific Disease States

Cancer: 25-35kcal/kg
Cancer, head & neck: 28-32kcal/kg, 30-40kcal/kg if weight loss
CKD Stages 1-4: 25-30kcal/kg
CKD Stage 5 on dialysis: 30-35kcal/kg
Cirrhosis: 25-35kcal/kg
Transplant, 6 months post-op: 25-30kcal/kg

Estimated Protein Requirements

DRI Reference: 0.8g/kg body weight
Adult maintenance: 0.8-1 g/kg
Older Adults: >1 g/kg
Renal disease: pre-dialysis (stage IV): 0.6-0.8 g/kg
Renal disease: hemodialysis: >1.2-1.3 g/kg up to 1.5-1.8 g/kg
Hepatitis (acute or chronic): 1-1.5 g/kg
Hepatic encephalopathy: 0.6-0.8 g/kg (BCAA) if refractory
Cancer: 1-1.5g/kg, 1.5-2.5 if cachectic
Bone Marrow Transplant: 1.5 g/kg
Inflammatory bowel disease: 1-1.5 g/kg
Short bowel syndrome: 1.5-2 g/kg
BMI >27, normal renal/liver: 1.5-2 g/kg IBW
Obesity Class I or II, trauma (ICU): 1.9 g/kg IBW
Obesity Class III, trauma (ICU): 2.5 g/kg/IBW
Organ transplant: short term: 1.5-2 g/kg
Organ transplant: long term: 1 g/kg
Pregnancy: +25 g/d in 2nd & 3rd trimester
Pulmonary disease: 1.2-1.5 g/kg
Critical illness: 1.5-2 g/kg (burns, sepsis, traumatic brain injury)
Stroke: 1-1.2 g/kg
Pressure Injury: 1.25-1.5 g/kg

Estimated Fluid Requirements

Goals: Maintaining adequate hydration, tissue perfusion, and electrolyte balance.
Needs based on: body weight, body surface, and RDA.
Consider: insensible losses (skin and lung), measured losses (stool and urine), and fluid balance alterations due to metabolic changes (fever) and medical therapy (diuretics).

Factors Affecting Fluid Requirements

Fever: 13% increase for each 1 degree Celsius above normal (37oC is normal); 7% increase for each degree Fahrenheit.
Sweating: 10-25% increase
Hyperventilation: 10-60% increase
Extraordinary wound/fistula, gastric and/or renal fluid losses: Varies (based on average 24 hour output)

Nutrition Care Process

Step 1: Nutrition Assessment: Collecting and documenting pertinent information about a patient's food or nutrition-related history, biochemical data, medical tests, anthropometric measurements, nutrition-focused physical findings, and client history.
Step 2: Nutrition Diagnosis: Identifying the nutrition problem using standardized language.
Step 3: Nutrition Intervention: Planning and implementing interventions (MNT) to address the root cause (etiology) of the nutrition problem and alleviate signs and symptoms.
Step 4: Monitoring/Evaluation: Monitoring the patient's progress toward goals and re-assessing interventions if necessary.

Nutrition Screening

Typically completed within 24 hours of admission to an acute care facility or on the first visit to an ambulatory clinic or office practice.
Identifies individuals who are malnourished or at nutritional risk and determines if a more detailed assessment is warranted.
Completed by RN, DTR, RD, other healthcare professionals, or the patient.
Patients found to be at nutritional risk are referred to an RD for a full assessment.

Effective Screening & Assessment Tools

Simple: Easy to understand and use.
Efficient: Time-effective.
Quick: Can be administered quickly.
Inexpensive: Costs are minimal.
Low risk: Does not pose a significant risk to the individual being screened.
Valid and Reliable: Accurate and consistent results.

Quality of Screening & Assessment Tools

Validity: How well the tool measures what it is designed to measure (accuracy).
Reliability: The degree to which repeated, independent measurements of the same variable give the same value (precision); consistent results.
Sensitivity and Specificity: Used to assess validity.
- Sensitivity is the percentage of undernourished individuals correctly identified as being at nutritional risk.
- Specificity is the percentage of well-nourished individuals correctly identified as being not at nutritional risk.

Screening and Assessment Tools List

Nutrition Screening Tools:
- Malnutrition Screening Tool (MST)
- Malnutrition Universal Screening Tool (MUST)
- Nutrition Risk Screening (NRS 2002)
- Mini Nutrition Assessment (MNA) Short Form
Assessment Tools:
- Subjective Global Assessment (SGA) (1987)
- Patient Generated Subjective Global Assessment (PG-SGA) (1990)
- Mini Nutrition Assessment (MNA) Long Form

Data Collection for Nutrition Assessment

Biochemical Data: Lab Values
Medical History: Current/past medications, supplements, diagnoses, procedures, chief complaints, and family history.
Food/Nutrition Related History: Dietary habits, restrictions, likes/dislikes, allergies/intolerances, appetite, taste alterations, satiety, dentition, chewing/swallowing, and GI complaints.
Anthropometric Data: Height, weight, BMI, IBW, %IBW, UBW, %UBW, weight change, time frame for weight change, % weight change, and weight trend.
Nutrition Focused Physical Examination Findings:
- Physical Appearance: Muscle wasting, subcutaneous fat loss, edema, ascites
- Functional Assessment: Weakness, fatigue, decreased mobility, difficulty with ADLs
Client History: Occupation, activity patterns, functional status, readiness to learn, knowledge about nutrition, cultural and religious beliefs, socioeconomic information, food planning, purchasing preparation abilities, food safety practices, and food program utilization.

Documentation

Medical Record: A systematic record of a patient's medical history, current issues, and care.
Evaluated by Regulatory Agencies: The JC (formerly JCAHO), State Department of Health, CMS, and compliance with professional practice standards.
Legal Document: Subject to HIPAA Guidelines.

HIPAA - Health Insurance Portability & Accountability Act

It is a federal law enacted in 1996 to protect sensitive patient health information.
Ensures patient privacy and secure data collection.

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) was passed by Congress and signed into law by President Clinton in 1996.
Title I of HIPAA protects health insurance coverage when workers change or lose their jobs.
Title II of HIPAA establishes national standards for electronic healthcare transactions, national identifiers for providers, health insurance plans, and employers.
Title II also covers privacy and security of health data.
These standards aim to improve the efficiency of the US healthcare system by encouraging the use of electronic data interchange.

Medical Records

Medical records are divided into components including admission, clinical, and clinical record cont’d sections.
The admission record documents patient information like name, address, emergency contact, age, reason for admission, religion, occupation, HCP, HIPAA signature, screening forms, health insurance, and other relevant information
The clinical record contains a multitude of information including history and physical exams, social history, current complaints, and medical issues. Information from the clinical record cont’d section includes orders (requiring a signature), consultation reports, nursing notes, vital signs, height/weight, intakes/outputs, surgical reports, progress notes, nutrition notes, and discharge notes/records.
The admission record must include all the required information in a format accessible to the healthcare team and other necessary parties, like insurance providers.

Progress Notes

Daily updates on a patient's medical condition are entered into the medical record as progress notes.
Progress notes include clinical changes, new information, and the results of tests.
Nurses, doctors, physical therapists, dietitians, pharmacists, and other health care providers can all enter progress notes.

Charting

All medical record entries must be signed by the person making the entry and include their credentials.
Personal opinions are prohibited in medical records.
Entries should be written using professional language that avoids abbreviations that are unclear or have multiple meanings.
Institutions typically have approved lists of abbreviations to use and a banned list of abbreviations associated with medical errors.

Order Writing Privileges

Non-physician licensees write orders within their scope of practice.
Examples of nutrition-related orders include diet orders, enteral/parenteral regimens, nutritionally-relevant labs, anthropometric requests, and consultation requests (e.g., speech language pathologists).
Order writing privileges are dictated by state law, institutional policy and procedure, and governing medical bodies.

EMR Documentation

Electronic medical record (EMR) documentation styles include ADIME, SOAP, DAP, DAR, PIE, IER, HOAP, SAP, and SOAPIER.

ADIME vs SOAP

ADIME and SOAP documentation styles both facilitate nutritional care planning.
ADIME stands for:
- Assessment
- Diagnosis
- Intervention
- Monitoring
- Evaluation
SOAP stands for:
- Subjective (assessment)
- Objective (assessment)
- Assessment (diagnosis)
- Plan (intervention, monitoring, evaluation)

SOAP Notes

Subjective (S) Information obtained during verbal interviews with the patient, significant other, family members, nurses, aides, staff members, etc.
Objective (O) Factual, reproducible observations including medical diagnoses, anthropometrics, labs, medications, diet orders, etc.
Assessment (A) Interpretation of the patient’s nutritional status and risk level based on subjective and objective information.
Plan (P) Recommended ACTIONS for nutritional care.

Assessment (A)

The assessment (A) portion of the SOAP note incorporates data relevant to clinical nutrition decision-making.
Relevant data can include current medical problems, signs/symptoms, complaints, nutrition history, current diet order, intake, tolerance, medical and surgical history, medications, and supplements.
The assessment integrates information from the subjective (S) and objective (O) portions of a SOAP note.

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Description

This quiz focuses on energy requirements for various patient types, emphasizing the calculations recommended for critically ill and obese patients. Learn about the different predictive equations such as the Penn State University and Mifflin-St Jeor equations, and how they apply to specific medical conditions and populations. Test your knowledge of nutritional guidelines for hospitalized patients.