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 e 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 pl (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 Sa m 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. pl e 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. Sa m 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: e TC:mg/dL HDL: mg/dL LDL: mg/dL TG: g/dL pl Sa m 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