Section: CLINICAL NUTRITION SERVICES
Subject: NUTRITION ASSESSMENT, INTERVENTION, MONITORING
AND EVALUATION (Replaces D006A: Further Assessment and MNT
Intervention)
Policy #: D006A
Date Issued: 11/97
Date Revised: , 2/07, 5/07,
4/08, 6/09, 8/10, 9/11, 4/13,
9/13, 2/14, 3/15
POLICY:
Patients identified during the initial assessment or prioritization will be further assessed and receive nutrition
intervention when applicable.
PROCEDURES:
Dietitian

Further assessment may include any or all of the following (NCP Step 1. Nutrition Assessment*):

- Food / Nutrition History
- Biochemical Data, Medical Tests, and Procedures
- Anthropometric Measurements
- Physical Exam Findings
- Client History
- Comparative Standards
Based on the findings, the dietitian identifies a Nutrition Diagnosis and gains patient agreement on the
appropriate Nutrition Intervention.
-
-
When recommendations are made which require a physician order, the dietitian will:
o
Follow-up within 3 days to verify the physician’s response.
o
Send a notice to MD via Meditech of recommendations
If the physician does not respond to the recommendation through ordering the requested
service/product or through other entry in the medical record, the dietitian may:
▪
Discuss recommendation during Multidisciplinary Round and/or contacts the physician to discuss
the recommendation and documents the results of the discussion

Nutrition Monitoring and Evaluation: The dietitian monitors and evaluates the patient’s response to care;
the frequency of this is based on the type of intervention implemented. Monitoring and evaluation may
include reassessment, meal rounds, or medical rounds and may or may not result in new recommendations.
The results of monitoring and evaluation are documented in the patient’s medical record.

When nutrition goals are met and patient has been “Level 3” for at least two weeks, a dietitian may “sign
off” on a patient. The dietitian will document in the medical record that future follow up will be provided by
consult or when additional information by way of reassessment, meal rounds, or medical rounds suggests
further assessment/intervention is warranted.

Hand Off Communication** When the care of a patient transfers from one dietitian to another, there is a
“hand-off” of information about the patient. While the information may be written or verbal, there must
always be the opportunity to ask and respond to questions, in a timely fashion. Information communicated
during the “hand-off” includes the patient’s current condition, nutrition interventions implemented and the
patient’s response to the interventions.
*American Dietetic Association. International Dietetics & Nutrition Terminology (IDNT) Reference Manual (3 rd ed); 2010.
**Reference :Joint Commission’s National Patient Safety Goal #2: Improve the effectiveness of communication among
ATTACHMENTS: Neonatal Care Unit
P&P CROSS REFERENCE: Select Specialty, 6.271, Dietitian Documentation
Reviewed by: Marie Mahon RD, LD
Last Review Date: 9/2011; 4/2013; 9/2013; 2/2014
Reviewed by: Jessica Robinson
Last Review Date: 3/30/2015
(Policy #D006A: Page 1 of 2)
Section: CLINICAL NUTRITION SERVICES
Subject: NUTRITION ASSESSMENT, INTERVENTION, MONITORING
AND EVALUATION (Replaces D006A: Further Assessment and MNT
Intervention)
Policy #: D006A
Date Issued: 11/97
Date Revised: , 2/07, 5/07,
4/08, 6/09, 8/10, 9/11, 4/13,
9/13, 2/14, 3/15
PRIORITIZATION FOR FURTHER ASSESSMENT AND EVALUATION







Within 48 hours
Physician Referral
TPN / New Order for Tube Feeding
Unusual/incorrect diet order
Nursing Referral
Patient’s identified via Patient Rounds
A1C ≥8%
Wound vac’s


Other
Within 3 days
- All Rehab patients
- NICU status; <34 weeks gestation and/or <1800 grams
- Select Specialty: Physician & Nursing Referrals
- Select Specialty: All New Admissions
Within 7 days
- All others admitted to the Neonatal Care Unit
REASSESSMENT AND FOLLOW-UP* MINIMUM GUIDELINES
2X/week (5 days)
New or unstable PN
New or unstable TF
Severe malnutrition
1X/Week (5 days)
Stable PN
Stable TF
Follow-up based on patient’s care goals
Neonatal Care Unit
* Follow-up may include reassessment, meal rounds, medical rounds, or brief documentation on intake or status. May or may not
include new interventions.