My ADA

Medical Nutrition Therapy Documentation

The medical record is a legal document that is maintained for communication of care, and includes a description of the care provided and delineation of who provided the care to the client. The government, private insurance companies and healthcare accrediting agencies mandate that the medical record be complete, accurate, and retained for a number of years as stipulated by Medicare or state laws. Reimbursement is dependent on documentation. One example of a valuable resource to review is Health Care: Consultants' Billing Advice May Lead to Improperly Paid Insurance Claims GAO-01-899T June 27, 2001, accessible at http://www.gao.gov.

Because of the brevity of the following explanations, the reader should refer to source documents for complete and accurate interpretation of any regulation. Although the following points highlight many of the important principles of MNT practice, they certainly do not incorporate them all.

Documentation

Communication among team members is important to provide consistent, quality care to persons with diabetes and renal disease. Documentation is one form of communication and is a necessary part of medical care. Documentation is also essential for verifying the quality of care delivered and determining outcomes of care.

What to document
The RD will find that the ADA MNT Evidence Based Guides for Practice (protocols and practice guidelines) provide resources for supporting that the RD meet the following documentation essentials. The dietitian documents the following in the patient's medical record:

Initial MNT

Receipt of referral, and name of primary dietitian
Diagnosis
Time and date of the visit.
Demographic data, measurements
Nutrition Assessments -- Nutrition history
Baseline data intake
Learning needs assessment r/t MNT
Clinical and behavioral goals -- Care Plan
Interventions -- MNT provided
Adherence potential
Scheduling of follow-up appointment

Follow-up MNT Sessions

Time and date of the visit.
Lab data and measurements
Progress to goals
Adjustments to CarePlan
Interventions -- New and reinforcement
Barriers and solutions
Next Follow-up appointment
Appointment failures, and other ways that the patient is not cooperating with the therapeutic plan
Follow-up plans

Dos and don'ts of documentation
Here are some tips to help improve your charting

Do

Check that you have the correct chart before you write.
Chart a patient's refusal to allow treatment. Be sure to report this to the patient's physician.
Write "late entry" and the date and time if you forgot to documentsomething.
Write often enough to tell the whole story.
Chart preventive measures.
Chart contemporaneously (contemporaneous notes are credible).
Write legibly, offering concise, clear notes reflecting facts.
Chart what you report to other healthcare providers.
Chart solutions as well as problems.
Document your observations. Write only what you see, hear, feel, or smell.
Encourage others to document relevant information that they share with you.
Document circumstances and handling of errors.
Chart your efforts to answer your patients' questions.
Chart patient/family teaching and response.
Chart all referrals/support efforts.

Don't

Chart a verbal order unless you have received one.
Chart a symptom (for instance: c/o excessive thirst), without also charting what you did about it.
Wait until the end of the day and rely on memory.
Ever alter a record. If you make an error, do mark through it with one line, indicate you are making a correction, and initial (or sign) and date.
Document what someone else said they heard, saw, or felt (unless the information is critical -- then quote and attribute).
Write trivia: "a good day." (What does that mean?)
Be imprecise. Avoid terms like "large amounts" and "appears."
Write your opinions.
Blanket chart or pre-chart. It is considered fraud to chart that you've done something you didn't do.