Dietitian’s Guide to Assessment and Documentation takes an investigative approach to nutrition assessment – reviewing the collection and analysis of evidence to determine the real nutrition-related problem, understanding the underlying problem and its effect on nutritional status, and providing intervention to address the problem - thereby improving nutritional health.
This text will help students learn how to:
- Formulate interview questions
- Create goals and patient teaching strategies
- Interpret lab data
- Write a care plan
- Document in a medical record
This Guide, which utilizes standard Nutrition Care Process language, outlines the key steps to help students and dietitians learn how to administer a thorough assessment and understand the proper documentation. These skills are essential in the treatment of patients as well the prevention or defense of lawsuit and the preparation for Joint Commission or State survey. Dietitian’s Guide to Assessment and Documentation also includes a reference section for interpretation of lab data and an appendix with commonly used abbreviations.
Features & Benefits
- Interpretation of Lab data in tabulated form for easy reference.
- Good interviewing skills for a thorough assessment as well as up to date information on the use of dietary supplements.
- Developing learning objectives and writing a care plan.
- Patient teaching on specific medical conditions.
- An appendix with commonly used abbreviations.
Advanced and Undergraduate level Nutrition and Dietetics courses.
Chapter 1 Chart Review
Chapter 2 The Interview
Chapter 3 Objective Tools Used to Collect Information for Assessment
Chapter 4 Assessment During Pregnancy and Lactation
Chapter 5 Pediatric Assessment
Chapter 6 Determining Nutrient Requirements and Writing Care Plan
Chapter 7 Patient Teaching
Chapter 8 Diet Teaching for Specific Medical Conditions
Chapter 9 The Legal Aspects of Documentation
Appendix Abbreviations and Symbols
Jacqueline Morris, RD, MPH, CDN-Executive Director, Annex Nutrition Services, Elmsford, New York
Jackie Morris RD, MPH, CDN hails from the beautiful island of Jamaica where she started her career in dietetics and nutrition. She graduated from the University of Technology in 1986 where she earned her Associate Degree in Food, Nutrition and Dietetics and worked as an assistant dietitian at the Falmouth Hospital. She also taught nutrition to high school students. In 1993, she migrated to the United States of America where she pursued her bachelor degree in nutrition at Lehman College and later a Master of Public Health degree from New York University. Ms. Morris consults with physicians and other health professionals on a variety of clinical conditions. Work experience includes Richmond Children Center, Bronx Lebanon Special Care Center, Danbury Hospital and Northern Manhattan Skilled Nursing Facility. She was the editor of the Beth Israel Cancer Center Newsletter, where she wrote several nutrition articles, including “ ‘Phyte’ Back with Phytochemicals.” In 2003 she started her own consulting firm, Annex Nutrition Services in Elmsford, NY. Annex Nutrition Services offers continuing education credits to dietitians, nurses, dietetic technicians and students, as well as private counseling both at home and in-office. She works in collaboration with other companies to provide wellness programs at the corporate level.