Dietitian's Guide to Assessment and Documentation

Book excerpt: 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, how to create goals and patient teaching strategies, how to interpret lab data, how to write a care plan and how to document in a medical record. This book is needed to help the dietitian do a thorough assessment and understand the proper documentation to prevent lawsuit, or defend the dietitian in a lawsuit, as well as prepare the dietitian for Joint Commission or State survey. Includes a reference section for interpretation of lab data and an appendix with commonly used abbreviations.