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sopie charting

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									Langara College GNS Dietetic Internship


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Appendix 1


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Appendix 2

Becoming Familiar with Patient Care Areas


Appendix 3

Guidelines for S.O.A.P Charting

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Appendix 4

Interviewing Tips & Techniques


Appendix 5

Patient Profiles

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Appendix 6

Formulae & Nutritional Solutions Chart


Appendix 7

Laboratory Value Chart

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Appendix 8

Medication Chart


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Appendix 1 Glossary

Administrative Dietitian A specialist in human, financial and capital resource management of food services system, ultimately providing high quality food. Client An individual in the community who have services provided to them by Community Health Professionals. Clinical Dietitian A specialist in therapeutic and normal nutrition, the clinical dietitian is responsible for the assessment of the nutritional status of patients with a condition, illness or injury that puts them at nutritional risk. The dietitian then plans implements and evaluates the results of the client’s nutritional care plans, in conjunction with the client. Responsibility may also include carrying out or collaborating in studies requiring the planning coordinating, collecting and interpreting of nutrition data. Community Dietitian A specialist in applied human nutrition with a focus on health promotion and disease prevention and is responsible for nutrition in a variety of community settings. This Dietitian assesses, plans, coordinates, implements, and evaluates nutrition intervention programs. Methods of intervention may include education, consultation, direct service, marketing, advocacy and policy development. This dietitian may initiate, develop, conduct and participate in nutrition studies or other research with a nutrition component. Competency A grouping of related knowledge, skills and attitudes that correlate with performance or behavior. The performance then can be measured against standards. This program provides the framework for achieving the competencies set out by the Dietitians of Canada in their Dietetic Internship Program Procedures Manual. Continuing Care The type of care provided individuals who can no longer manage in their own homes, and now reside in a facility where medical care is available. This was previously called Long Term Care.

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Continuum of Care An inclusive progression of care that includes at home care, hospital care and continuing care facility residency as required by clients Department Director The Registered Dietitian or Food Service Manager responsible for the daily functioning of the Food Services Department. This person may or may not be the Supervising Dietitian. Dietetic Intern An individual who is enrolled in an accredited internship program, after having completed the academic requirements as defined by Dietitians of Canada. Entry-level The level of proficiency most often associated with, but not necessarily describing, individuals entering practice. The entry-level dietitian is competent in the application of knowledge and skills considered essential to entry-level practice. Internship Coordinator Reporting to the Internship Director, the person(s) who directly oversee the day to day aspects of the dietetic internship. Internship Director The person responsible for the planning, co-ordination and evaluation of the dietetic internship program. Patient Individuals in need of medical intervention that are in acute care facilities. Resident An individual residing in a continuing care facility. Rotation A scheduling tool used to organize the program to provide the dietetic intern with a variety of opportunities in order that she/he achieves all the competencies. Supervising Dietitian The clinical or administrative dietitian/nutritionist who accepts responsibility for the intern while the later is in the facility. To the best of her/his ability, the supervising Dietitian will assist the intern in achieving the competencies by providing the learning experiences outlined in the enabling activities. The supervising Dietitian will evaluate completed assignments and assess the intern’s performance, given the rating scales and evaluation forms provided. Page 4 of 17


When you start in a clinical setting, there are many things you will need to locate. Start each clinical rotation with this assignment, and keep your notes handy throughout the rotation so that you can be more independent. It is more for your own use, than for a hand-in assignment. When you cannot find the answer by looking around, then ask the Supervising RD.
1. Floorplan  How many patient care units are there in the building? How many on this floor? How are they named? What are the telephone locals?  What is a “med” room? Where is it?  How do you find out which room patient/residents are in?  Are all patient/resident rooms alike?  If there is more than one person in each room, how is each bed numbered?  Besides patient/resident rooms and the nursing station, what other areas are located on the floor? Can patient/residents access these areas? May you access these areas?  Where are the current patient/resident charts kept?  Where are old charts for current patients/residents kept?  Where is the staff washroom?  Is there a ward kitchen? Who is allowed to use it? When is it re-stocked and what is stocked there?  How and where are patient/residents weighed? 2. Resources  Where is the CPS? What will you find in the CPS?  Where is the medical dictionary?  Where is the Manual of Nutritional Care?  Where are the nutritional references  Where is the telephone book? 3. Communications  How do you determine a patient/resident’s primary physician? Primary RN? How would you communicate with them?  Is there a cardex? What kind of information can you get from the cardex?  How does the patient care unit communicate with the Food Service Dept. and the RD when a new patient/resident arrives?  How are referrals to the RD made?  How does the RD communicate with the care staff?  How does the RD communicate changes with the food production and service staff?  In Acute Care specifically:  What is the hospital’s policy regarding discharge?  What are Holter signs? What are the requirements for changing the signs, confirming patient identity  What happens when a patient status is changed from acute care to long term care?  Beds are funded for hospital services –medical, surgical, pediatric etc. How is that distinction made?

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The goal of SOAP charting is to provide relevant information, in a concise manner, relating to the patient’s nutritional care. It is rare that an initial chart entry will require more than one page in the Nutrition Report. Many facilities now have standardized forms with tick-boxes for an initial entry. The following is a guideline for SOAP charting. Suggestions as to the type of information to be included in each section are outlined. Documentation should be factual and impressions should be clearly stated as such. Charting should not criticize prior care. SUBJECTIVE DATA:  Source (where did information come from) - i.e. patient, family, caregiver, significant other, or medical record  Symptoms, complaints, concerns  Stated Wt. Hx. - usual wt., goal wt., rate of recent wt. change, etc.  Significant diet hx. – current habits, previous therapeutic diets, adherence to previous diets  Food allergies or intolerances  Vitamin/mineral supplements taken  Lifestyle – activity level, out of home eating patterns etc.  Socio-economic and cultural patterns  Direct patient quotes are helpful OBJECTIVE DATA:  Diet order - current, when implemented  Source – medical record, other patient records, measurements  Data relevant to nutritional assessment  Relevant lab data  Medications  Medical history  Anthropometric data – Ht., Wt., IBW, BMI, Wt change while in hospital – dated  Dietary Data – Nutrient intake analysis or calorie count

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ASSESSMENT DATA  Assess: o pt.’s nutritional status based on subjective and objective data o appropriateness of diet order – recommend changes as needed o adequacy of intake o nutritional requirements Evaluation of diet hx. – Relevant nutrients etc. Desirable wt. range or realistic wt. goal or rate of wt. change Assess : o need for education o pt.’s comprehension, motivation adherence o pt.’s ability to tolerate and/or meet nutritional recommendations

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PLAN      outline of Nutrition Care Plan, based on assessment o Recommendations: Diet order change, diagnostic tests, specific supplements, education, referrals, etc. Specific course of action taken or to be taken Document instruction to be given Plans for referral to outpatient nutrition follow-up or education This is the section most likely to be read by other members of the team

GUIDELINES ON DOCUMENTING      Be legible Use only approved or standard abbreviations Do not obliterate anything in the medical record (no liquid paper!) To delete a word or statement, cross it out with a single line, bracket, and initial (like a cheque). Nutrition reports should be timely. Do not insert back dated notes into the chart. If necessary, write an addendum and date it. Do not make uncomplimentary remarks about patients, significant others or the care received – either currently or previously – Remember that patients and courts can access the medical record.

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______________________________________________________________________ DEFINITION: (According to Webster’s) – An Interview is:  A meeting at which information is obtained.  A formal consultation to gather information guided by specific goals PURPOSE OF THE INTERVIEW In Dietetics, it is a method used by the Dietitian to:  Gather information about an individual’s eating style, food choices, and the factors effecting those variables  Observe and gather an individual’s responses, and assess non-verbal communication cues  Evaluate specific needs The Dietitian is responsible to guide the interview in such a manner that the desired or required information is accurately captured. Helpful Hints  Prepare for the interview – know what you want to you find out  Have specific topics to cover and goals to achieve  Explain why certain questions are asked  Listen actively and attentively  Communicate simply and effectively Be aware of both the verbal and non-verbal aspects of the interview. This applies to both how you communicate with the client and how that client communicates back to you. Verbal behaviors  Appropriate voice, tempo and volume  Simple words instead of jargon  Clear articulation  Conciseness  Avoid verbal ticks – such as um, uh, you know, okay, right, like etc. Non-verbal behaviors  Facial expression  Posture  Physical movements and gestures  Eye contact  Dress and grooming Page 8 of 17

Your actions will show the degree to which you respect the person to which you are speaking. Effective listening skills are  Pause occasionally to allow the person to catch up with the train of thought  Encourage the person to provide complete information  Paraphrase for clarity  Empathize  Create a supportive environment – do not be judgmental  Be open to new ideas Other points  Find out if the client has a hearing impediment – make sure you sit on the correct side.  Make certain that this is a good time for the interview to occur. If not, is there another, mutually agreeable time?  Ensure privacy. THE INTERVIEW ITSELF…… Opening the Interview  Develop rapport – create a warm and friendly environment  Consider the person’s comfort (which chair will each person sit in)  Determine if there are any special needs – hearing difficulties, speaking struggles, etc.  Proper introductions  Clarify the nature and purpose of the interview  Explain how the information will be used and how each will benefit from the interview Middle of the Interview  This is when you start asking specific questions  Have a pre-planned and prepared interview guide. If you can keep it all in your head – that’s best. Otherwise have some notes in front of you  BUT keep note-taking during the interview to the minimum needed. It can be distracting  Use open ended questions to encourage discussion  Avoid closed questions – they will only give you a “yes” or a “no” answer.  Limit “why’s”, as they can be intimidating. Initially, questions should encourage the interview subject to talk 60-70% of the time.

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Topics you may need to find out (or confirm) Try to think of tactful ways of asking difficult questions. Ask others how they approach difficult topics.  Chewing ability  Ability of the hands to work (prepare foods, cut plated foods)  Elimination – bowel/bladder control etc.  Thirst, fluid consumed  Food preparation knowledge  Desire to comply with nutrition care plan  Economic situation  Living situation

Closing the Interview  State appreciation  Allow for the expression of further concerns or comments  Summarize the main points discussed.  Arrange a time for the next meeting - i.e. for nutrition counseling or follow up visit.

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Checklist of Counselor’s Interviewing Techniques
Nonverbal Behavior  Eye contact  Facial expression  Body orientation  relaxed  leaning forward  facing client  Distance (3 – 5 feet or 1 – 1.5 meters apart) Rapport Building  Identified self  Verified client’s name  Explained purpose of interview  Nonjudgmental responses  Appropriate jargon  Showed empathy and support Verbal Behavior  Appropriate voice level and pitch  Fluent speech  Professional style NOT conversational style  Encouraged patient participation  Kept the session on track  Provided accurate organized diet instruction  Evaluated patient’s understanding/acceptance of diet Listening Responses     Clarification Paraphrasing Reflection Summarization

Action Responses      Probing Attributing Confronting Interpreting Self disclosure

Conclusion   Summarized results Informed patient of follow up sessions and how to get in touch if further information is needed

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Throughout the internship, you are asked to complete patient profiles. The purpose of this is to provide you the opportunity to delve deeper into a patient/resident’s medical situation and truly see the “big picture” or the entire care of the individual. A Patient Profile will include:  Medical history - Each disease or condition is defined with nutritional implications (included)  Current medical concerns - Each condition is defined with nutritional implications highlighted  Laboratory value history  With implications/reasons for each value provided  Medications - With each described to include reason for prescribing, and interactions  Anthropometrics & other measures. - as available and why they are relevant to the care of this resident  Nutritional history - how each factor is impacted by the history  Nutritional Assessment & Care Plan  With justification for item – how it is related to the nutritional assessment, how each goal and objective is related to the individual and medical concerns.  Interventions of other members of the health care team.  Prognosis  Continuing inventions planned. This is to be complete in report form, but points or bullets are acceptable.

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Sample Case Study Discussion Outline
A case study is to be prepared during the course of the clinical rotations. It is to be thirty minutes in length. Other health care professionals should be invited to attend. A written report is to be submitted to the Supervising Dietitian and the Internship Coordinator upon completion of the presentation. The following is a guide to prepare the case study and may be revised upon discussion with the Supervising Dietitian and/or the Internship Coordinator as to the nature of the study. Resident Profile  name by initials only  height, weight, body mass index  age  pertinent family, psycho-social information Reason for Involvement  relevant problems Nutrition Assessment  assessment of nutrition status  significant aspects of nutrition history  nutritional requirements  nutritional counseling or educational requirements  challenging or controversial aspects Implementation of Nutrition Care Plan  goals of care plan  aspects of implementation which contribute to goals being met or not met  revisions to care plan  involvement of other professionals Evaluation of Nutrition Care  methods used to evaluate nutrition care  describe which goals are and are not being met  challenging aspects of this case Prognosis  issues regarding adherence to care plan  implications of nutritional management to lifestyle  discharge planning (if appropriate)  community resources that may be available

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Throughout the internship you will be asked to compare the formulae available at a hospital or facility. Use a form in this format to do so.

Formulae available W X Y Name of Formula Method of delivery Kcal/ml Protein/ml & type of protein Carbohydrates/ml & type of carbohydrate Fat/ml & type of fat Nutrients included/ml Unique features Conditions most suited to be treated with this formula Cost/ml Availability outside of hospital


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Throughout the internship your assignments will include ones that ask you to examine laboratory results and explain the impact they have on the nutritional assessment. The following chart is provided to assist you. When doing the assignment, it would likely suit the requirement better to put it sideways on the paper (landscape).

Hgb Mg Alb FBS Alk Phos WBC Na Prealbumin RBG GGT AST RBC K+ B12

HBA1C Bilirubin Hct Cl Folate Microalbumin Ammonia Fe CO2 Total Chol Urea (BUN) SGOT Ferritin PO4

HDL Chol Creatinine Amylase TIBC Ca LDL Chol Homocysteine Lipase Transferrin Ionized Calcium Triglycerides T4 Osmolalit

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Laboratory parameter

Normal Range

Elevated value Indicates Nutritional : implication

Lower value Indicates Nutritional implication


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Throughout the internship you will be requested to make notes of the medications that the patients you interact with. The chart below is designed to assist that process. It will likely suit your purposes better to put the chart on the paper sideways.

Medication Name


Action on the body

Food/nutrition interaction.

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