Spreadsheet: 780953d1652886471-trying-to-calculate-page-to-include-zeros-and-n-aa-book-1
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Quality | Clinical Nutrition Documentation Standardization Audit | Month:                                            Reviewed by :
Productivity | Interventions per day avg. =
CRITICAL LEVEL | Complete the Data for each patient reviewed x 4 charts. | Sample 1 | Sample 2 | Sample 3 | Sample 4
 | DATA TYPE- Medical Record #/ or initials of pt. |  |  |  |  | Instructions: Review pt assessment in meditech -- Review>Assessment> Nutrition Assessment> for every missing field replace 1 with 0- add comment below, the % will automatically populate with score.
 | Age group: N=Neonate 0-1 yr, I = infant 1-2 yr, P = peds 2-12 yr, Ad = adolescent 13-18 yr,   A =adult >18 -74 yr,   G = geriatric (> 75 yrs)
 | Sample Type- PO/EN/TPN/malnutrition dx
 | Admission date
1 | DOCUMENTATION - collection of Data |  |  |  |  | Descriptors
1 | Nutrition Assessment Trigger -- on time within 1-2 day of notification? | 1 | 1 | 1 | 1 | Follow P&P Assessment/Reassessmen
3 | Nutrition Related History/Interview or Chart Review completed. Preferences obtained from Patient/Family/Other or why if unable to get them. Menu discussion | 1 | 1 | 1 | 1 | diet hx/swallow/intake >5 days,pain, end of life, etc./ why?
1 | Nutrition Order includes modifiers and supplements ordered | 1 | 1 | 1 | 1 | current diet order in Meditech
1 | Nutrition Intake - current intake -(interview, chart review) | 1 | 1 | 1 | 1 | NPO ? Days, meal %s x meals x days
1 | Nutrition Support  - noted and evaluated/TPN meets criteria or not | 1 | 1 | 1 | 1 | EN or PN order in Meditech
1 | Weight History - pt reports/ chart review/answer why weight loss ? | 1 | 1 | 1 | 1 | caluculate % of wt loss here /over time
1 | Do not use unapproved Abbreviations / Safety | 1 | 1 | 1 | 1 | The Joint Commission
1 | PHYSICAL ASSESSMENT : collection of data
1 | NFPE Completed /if not why? | 1 | 1 | 1 | 1 | comment on pt mentation here
1 | Intervew/chart review includes skin/edema/GI/resp/pain/mental/swallow/functional | 1 | 1 | 1 | 1 | chart by exception here.
1 | Malnutrition :  rule in or out - obvious s/s of muscle or fat wasting or not | 1 | 1 | 1 | 1 | for malnutrition - add S/S in PES
2 | NUTRITION CALCULATONS :  critical thinking
2 | Comparative Standards Comments --weight if not actual used? | 1 | 1 | 1 | 1 | comment if wts are estimated
2 | What standards used to calculate needs.  ASPEN or --predictive equation. | 1 | 1 | 1 | 1 | use the standards
2 | Answer question-  are they able to meet intake goals or not with current diet order? | 1 | 1 | 1 | 1 | current intake/estimated needs
2 | PLAN OF CARE - NUTRITION DX : crttical thinking review of data
2 | Nutrition Problem / if Malnutrition #1 problem:  ruled in or out? | 1 | 1 | 1 | 1 | pick a problem you can help resolve or lessen the s/s.
2 | Nutrition Etiology | 1 | 1 | 1 | 1 | answer why or what is the main cause
2 | Nutrition Signs.Symptoms /Malnutrition needs 2 indicators per ASPEN/GLIM | 1 | 1 | 1 | 1 | Use 2 or more indicaters, the more the merrier!  Pick from the pic list first> free text
3 | PLAN OF CARE - NUTRITION INTERVENTION : implementation
3 | Interventions are individualized and appropriate for the patient. It is directed at changing the etiology, but if not possible to change the etiology, it is directed at reducing the impact of signs/symptoms. | 1 | 1 | 1 | 1 | pick from the pic list and then free text specific goals
3 | Goals are SMART, specifc, measurable, achieveable, realistic, time frame | 1 | 1 | 1 | 1 | time frame to reach goal is ?
3 | Nutrition prescription specifies exact physician orders in Meditech | 1 | 1 | 1 | 1 | exact diet order plus A&M or recom
3 | Education -  yes or no and if not reason why not.  Formal in Teach Edu ("5 min rule") | 1 | 1 | 1 | 1 | pt should participate in POC,
3 | Evidence of Collaboraton - telephonic/electronic/Meetings/Rounds | 1 | 1 | 0 | 0 | may include SLP/GI/Surgeon/PSM/Nurse/MD
1 | MONITORING-EVALUATION (Reassessments)
1 | Acuity level assigned -  drives reassessments and case load/mon staffing. |  |  |  |  | High Acuity < 4 day   Moderate Acuity <7  days Low Acuity - > 10 days
1 | Reassessment - evaluate progress towards goal | 1 | 1 | 1 | 1 | timeliness, progess, adjusted?
 | Comments:
 | Level 1  Level 2    Level 3         Total
 | Critical (<70%) | 40 | 24 | 24 | 160 | 1
 | Needs Improvement (70-89%) |  | 2 | 3
 | Passing (>90%)
 | Total Possible | 40 | 48 | 72 | 160
 | Performance to  Goal     > 90% | 1 |  |  |  | 1