In our LTC, we have been care planning for q one that is not on a regular diet w/o any nutritional issues/dehydration issues. We did well w/ our state survey, No citations. I had spoken to the RA that comes in q month as our consultant, she was the one that stated that q one in the facility needs to have a nutritional care plan unless they are on a regular diet and all is fine. My ? is we are doing away w/ this process, by only care planning for those who are fed via feeding tubes, wt loss or some other issues. Our diabetics will be cp together with nursing and dietary interventions underneath. If the resident is on a mechanically altered diet or theraputic diet no care plan unless wt or skin etc is an issue...HELP. Thanks Tex:
Sep 5, '02
When a Nutrition RAP is triggered because of a mechanically altered or therapeutic diet, even though the resident presents no problem with these nutritional approaches, what do you write on the RAPs sheet?
Should you consider a progress note of a Dietitian a care plan itself? Absolutely!
In this case and scenario, when a Nutrition RAP is triggered but there is no actual problem, all you have to say under RAP documentation is... "See Dietitian's Progress Note date XX/XX/XX"
A Dietitian's progress note would summarize....
"Resident remains on a 2-gm Na chopped diet; consumes more than 75% of each meal serving, including fluids. No complaints presented regarding diet. Weight has been stable in the last three months. No signs of dehydration. Will continue same approaches."
The primary concern is decrease in nutritional intake due to the use of a low Na diet (which may not be so palatable) and the consistency - chopped. If these approaches do not affect the resident's intake, why create a specific Nutrition Care Plan in a separate sheet?
Last edit by Talino on Sep 5, '02