Dietitian's Guide to Assessment and Documentation

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.

Key Features

• Provides Interpretation of Lab Data in Tabulated Form for Easy Reference.
• Teaches Students the Good Interviewing Skills Needed for a Thorough Assessment.
• Explains How to Develop Learning Objectives and Write a Care Plan. 
• Provides Guidance for Patient Teaching on Specific Medical Conditions.
• Includes an Appendix With Commonly Used Abbreviations.

Table of Contents

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