i • Chronic Obstructive Pulmonary Disease Toolkit
Table of Contents
Acknowledgments............................................................................................................................................................................................................ii
Overview of Chronic Obstructive Pulmonary Disease Toolkit..........................................................................................................................1
Medical Nutrition Therapy Protocol Documents
for Implementing Chronic Obstructive Pulmonary Disease Evidence-Based Nutrition Practice Guideline
Chronic Obstructive Pulmonary Disease Evidence-Based Nutrition Practice Guideline:
Executive Summary of Recommendations............................................................................................................................................8
Medical Nutrition Therapy Flowchart of Encounters for Chronic Obstructive Pulmonary Disease................................ 12
Medical Nutrition Therapy Encounter Process for Chronic Obstructive Pulmonary Disease............................................ 14
Standardized Language Terms Associated with Chronic Obstructive Pulmonary Disease Recommendations........ 19
Documentation Forms
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Instructions for Medical Nutrition Therapy Sample Referral Form............................................................................................. 34
Sample Referral Form: Referral for Medical Nutrition Therapy..................................................................................................... 35
Medical Nutrition Therapy for Chronic Obstructive Pulmonary Disease Initial Progress Note........................................ 36
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(Attachment: Electronic Version)
Medical Nutrition Therapy for Chronic Obstructive Pulmonary Disease Follow-up Progress Note................................ 38
(Attachment: Electronic Version)
Case Study for Chronic Obstructive Pulmonary Disease................................................................................................................ 40
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Outcomes Management
Outcomes Management: Nutrition Monitoring and Evaluation................................................................................................. 46
Outcomes Management Forms in Excel............................................................................................................................................... 52
(Attachment: Electronic Version)
Client Education Materials and Professional Resources
Summary of Client Education Materials and Professional Resources........................................................................................ 53
COPD and Nutrition: Guidelines for Healthy Eating When You Have COPD............................................................................ 57
Note: The toolkit PDF contains additional files. To access these additional toolkit files, click on the paper clip on the lower left or select View
> Navigation panels > Attachments from the menu bar.
© 2012 Academy of Nutrition and Dietetics. All rights reserved.
1
• Chronic Obstructive Pulmonary Disease Toolkit
Overview Chronic Obstructive Pulmonary Disease
(COPD) Toolkit
Introduction
The Academy of Nutrition and Dietetics COPD Evidence-Based Nutrition Practice Guideline
incorporates systemically reviewed scientific evidence for COPD. The guideline defines evidence-based recommendations, which guides the food and nutrition practice decisions and
increases the likelihood of use of evidence-based interventions by the registered dietitian
and the likelihood of achieving positive patient outcomes.
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The COPD Evidence-Based Nutrition Practice Guideline can be accessed online in the Evidence
Analysis Library at www.andevidencelibrary.com. The information within the guideline and
toolkit were derived based on the Academy’s rigorous and systematic process of analyzing
scientific research. Within the guideline, you will find the guideline introduction, evidencebased recommendations and clinical algorithms that relate to COPD. The COPD evidencebased recommendations within the COPD guideline utilized research from January 1995
through July 2006. Research published after this time on the topic of COPD has not been
systematically analyzed for inclusion in the Evidence Analysis Library or this toolkit and will
be included upon revision. The COPD Toolkit is designed to be used alone or together with
the COPD Evidence-Based Nutrition Practice Guideline.
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The COPD Toolkit contains the Medical Nutrition Therapy (MNT) protocol and documentation forms that can be used for the implementation of the guideline. This set of companion
documents focuses on the Academy’s Nutrition Care Process, which consists of the nutrition
assessment, diagnosis, intervention, and monitoring and evaluation. The primary goal of
MNT is to achieve and maintain appropriate body weight and quality of life. The COPD Toolkit
integrates components of the Nutrition Care Process.
Further, the toolkit is designed to be used in coordination with the International Dietetics &
Nutrition Terminology (IDNT) Reference Manual, Standardized Language for the Nutrition Care
Process.2 The Academy’s Standardized Language and related information that is common
or pertinent to COPD is imbedded throughout the toolkit. However, a user is expected to
refer to the IDNT Reference Manual for more information when needed such as additional
standardized language terms, reference sheets, definitions of standardized language domains and descriptions of using the language within each step of the Nutrition Care Process.
In addition, the order of the standardized language domains, classes and terminology is
consistent with that in the IDNT Reference Manual. To purchase the IDNT Reference Manual or
find more information on the Nutrition Care Process and Standardized Language see www.
eatright.org/Members/content.aspx?id=5477 (member link) or www.eatright.org/Health
Professionals/content.aspx?id=7077 (non-member link).
© 2012 Academy of Nutrition and Dietetics. All rights reserved.
35 • Chronic Obstructive Pulmonary Disease Toolkit
Referral for COPD Medical Nutrition Therapy (MNT)
Please attach current list of medications, dosages & current lab results.
*Required information for referral
*Date:
*Patient name:
*Date of Birth:
Insurance:
Medical Record Number:
Height:
*Day time phone number:
Weight:
Gender:
*Requested service (may check more than one option):  Initial MNT
*Reason:  Underweight:
 Follow-up MNT
 Weight loss:
 Other:
Provide the following labs as available.
**REASON FOR ORDERING MNT**
ICD-9 MEDICAL DIAGNOSES
Date:
BP:
(check all that apply below, required to initiate MNT service)
Chronic bronchitis
491.0
Simple chronic bronchitis
491.1
Mucopurulent chronic bronchitis
491.2
Obstructive chronic bronchitis
492
Emphysema
492.8
Other emphysema
496
Chronic airway obstruction, not elsewhere classified
261
Nutritional marasmus, includes Nutritional atrophy,
severe calorie deficiency, severe malnutrition NOS
%
HgbA1c:
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TC:mg/dL
HDL:
mg/dL
LDL:
mg/dL
TG:
g/dL
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Other:
mm Hg
glucose:mg/dL
491
783.21
783.22
Lab values:
Abnormal Loss of Weight and Underweight
Provide the following as available.
Relevant Medications and Dosages (type/frequency):
Current O2 Rx:
BUN:mg/dL
ALB:g/dL
Prealbumin:mg/dl
Creat:mg/dl
ng/ml
Vitamin D:
Steroid dose:
Relevant Lab Data (attach current lab data):
Bone density screening result:
Indirect calorimetry measurements (setting & REE):
Physical Activity Restrictions:
Comments: (e.g., medical conditions, enteral/parenteral nutrition)
Last related hospitalization admission/discharge dates:
MNT is a necessary part of the patient’s medical treatment for the medical diagnosis (es) listed above.
*Referring Provider’s Signature
NPI number:
Contact Name/Phone/Fax:
© 2012 Academy of Nutrition and Dietetics. All rights reserved.
Date