Patient medical records should show evidence that information on nutritional status or functional status is gathered through the application of screening criteria, when patients who are acutely or chronically unwell and who are experiencing dietary difficulties and deficiencies related to or resulting from their illness, first contact hospital services.

From the post Assessments within 24 hours (this link will open in a new tab of your current browser), it is clear that the initial medical and nursing assessments are completed within 24 hours of admission to the hospital  or when the patient’s condition indicates, the initial medical and/or nursing assessment are conducted and available earlier, for use by all those caring for the patient. This means that patients are screened for nutritional risk as part of the initial assessment with the application of screening criteria to gather information on nutritional status or functional status which is often done by nurses, must also be completed routinely within 24 hours of admission to the hospital or at an earlier time period.

Nutritional screening is usually undertaken by nurses and doctors; assessment by dietitians.

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Nurses use individual hospital screening criteria to identify patients with nutritional or functional needs like:

• unexpected weight loss
• gastrointestinal symptoms
• obvious emaciation
• pressure ulcers
• intravenous or tube feedings

In each case, the screening criteria are developed by qualified individuals with the aim to identify those who are malnourished or ‘at risk’ of becoming so and so able to further assess and, if necessary, to provide any required patient treatment. For example, screening criteria for nutritional risk may be developed by nurses who will apply the criteria, dietitians who will supply the recommended dietary intervention, and nutritionists able to integrate nutritional needs with the other needs of the patient.

Referencing of all tools available and screening criteria used  is beyond the scope of this single post. However, I like to share with you the desirable qualities of such tools used to carry out the screening which are namely (i) accuracy of the tool(sensitivity and specificity), (ii) easy to use, (iii) reliable so as to produce similar results with repeat testing in the same circumstances and with different users where the patient’s state has not changed it must be acceptable to those being screened, (iv) does not require extensive training, and (v) does not need additional equipment.

For your information too, two commonly used tools developed for hospital-wide application and used with older adults are (i) Mini Nutritional Assessment (MNA), and (ii) Malnutrition Universal Screening Tool (MUST).

Information through these kinds of screening criteria tools provides insight into the patient’s overall physical health. The information may also indicate that patients at risk for nutritional problems according to the criteria, receive further or more in-depth assessment of nutritional status or functional status, including a fall-risk assessment.   This information is viewed as the most effective way and an essential first step in the management of patients’ nutritional care.

The more in-depth assessment mentioned above may be necessary to identify the problem or potential nutrition risk(s) for those high risk patients in need of nutritional interventions and patients in need of rehabilitation services or other services related to their ability to function independently or at their greatest potential. Nurses refer these patients in need of a functional assessment according to the criteria to the hospital Dietitian for full nutrition assessment.. The dietitian will usually first review the medical record of referred patients. Everything from diagnosis, social history, medical history, medication, laboratory data and assessment, and evaluations performed by other medical/clinical personnel are scrutinised  According to Jacqueline (2011), reading the medical record which contains the notes of other clinicians provides necessary context for effective management of the condition(s) being assessed. A dietitian may then take anthropometric measurements in addition to a subjective nutritional assessment.

Subjective data pertaining to the nutritional assessment, identify abnormal findings and client strengths which could include for example, Patient A who is a female, stated age 42 years; reports she had a fever for 2 days a week ago; drinks 4 to 6 glasses of water daily) and anthropometric measurements i.e the objective data could include for example, Height: 5 feet, 5 inches (165 cm); body frame: medium; weight: 128 lb (58 kg); BMI: 21.3). The data is usually clustered to reveal any significant patterns or abnormalities. These data may then be used to make clinical judgments about the status of the patient’s nutritional health.

At this point, I like you to take note that the dietitian uses assessments techniques which vary for the mother and unborn child as well as the complications associated with pregnancy, the lactating mother, infants and children.

Once the dietitian has a a clear understanding of the medical diagnosis and its nutritional implications, intervention is initiated, the patient is carefully monitored to ensure that goals are met and the desired outcome is achieved.

Do take note that if you are working at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, your hospital will need to comply with JCI Standard AOP.1.6 which states that “Patients are screened for nutritional status and functional needs and are referred for further assessment and treatment when necessary.”

I am sure you are already aware that your hospital has in place a program which evaluates its patients’ risk for falls – which could include fall history, medications-and-alcohol-consumption review, gait and balance screening, and walking aids used by the patient, and monitors both the intended and unintended consequences – for example, the inappropriate use of physical restraints or fluid intake restriction which may result in injury, impaired circulation, or compromised skin integrity of measures, taken to reduce falls.

JCI believes that compliance to JCI Standard AOP.1.6 as part of the initial assessment using criteria developed by qualified individuals to identify patients who require further functional assessment, further strengthens a hospital’s fall-risk reduction program.

It is common in hospitals when patients are provided dietetic services after dietary orders by the doctor attending are documented in the patient medical record. Health Information Management (HIM) / Medical Records (MR) practitioners will find within medical records, progress notes with the nutritional care of the patient met in accordance with the doctor’s orders and also the Dietary Progress Note, a progress note documented by the hospital dietitian as part of recognised dietary practices which includes:

• patient’s dietary needs
• any dietary observations made by staff (e.g., amount of meal consumed,food likes/dislikes, and so on)

HIM / MR practitioners who are members of a closed Medical Record Review, need to be aware that the Medical Record Review Tool will assess and determine the degree of compliance with standards and elements of performance relating to nutrition care given by the JCI Standard AOP.1.6, when there is evidence in the medical record of patients screened for nutritional status and functional needs.

References:

1. Jacqueline, CM, 2011, Detitian’s guide to assessment and documentation, Jones and Bartlett Publishers, Sudbury, MA, USA
2. Janet, W, & Jane HK, 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, PA, USA
3. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
4. Nutritional screening and assessment, Nursing Times.net, viewed 17 February 2013, < http://www.nursingtimes.net/nutritional-screening-and-assessment/199381.article >
5. Using nutritional screening tools to identify malnourished patients, Nursing Times.net, viewed 17 February 2013, < http://www.nursingtimes.net/nursing-practice/clinical-zones/nutrition/using-nutritional-screening-tools-to-identify-malnourished-patients/1958881.article >
6. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
7. Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA