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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.