Cc ical Case Log ‘A copy of your facilities Nutritional Assessment form OR the Encounter Form must aceompany all entries to the log. As an inter you will document in the ranmer thea 's sexpuised Sor your facility plus submitting the form fos the medica} condition that is being treated incorporating “he NC? steps (Diagnosis, Intervention, Monitoring & Evaluation). If you are submitting your facilities assessment form, you must include a Nutrition Diagnosis (PES statement) on each, Please note that patients/residents are very rarely admitted with one medical condition. As an intern ‘you want to be exposed to a variety of diagnosis’s/medical conditions in which nutritional intervention is essential. Each encounter checked for the medical conditions listed below should be addressing the sunikiomal care c condition or prodicat, Below is a list of the material needed in each Module. Insert the date the encounter was completed and cross-reference each entry with the note or draft. Do not include any patient resident identifiers (Le. names), ‘The Registered Dictitian (RD) must sign each encounter or assessment form. 1. Uncomplicated Medicat Conditions ~ Mininum 15 medical record reviews with corapleted Encounter Forms Please indicate the date of the note addressing the required medical condition below. Example: 10/28 Hypertension ___ Diabetes Mellitus - Type 2 Hypertension TY. Dysphagia 7 Diverticular Disease CHF 1 Low BMI "J Inadequate intake of protein and/or energy. "_ Muscle loss and/or Loss of subcutaneous fat Pressure sore. ‘Cancer Gt Disease Alzheimer’s Diseas Drug and Nutrient Interactions 2/5. Significant Weight Change Osteoporosis, Other- CV) 24 Other - By it 1/24 Other - nO tog oie perp injury (AKI) i set MAINE ITIP Other “Small Baw/t | Opstrustion Others11. Complex Medical Conditions- Nutritional Assessments ~ Minimum 5 medical record reviews Renal Disease Liver Disease Acute COPD. [2 TPN — initial 124 TPN - FU Enteral feeding — initial Enteral feeding - F/U TS Post-surgical Transitional feeding V2 Ventiiator dependent Other - Other - Other - Other - IIL. Case Study Case Study Evaluation Form Je adel in Case Study Module IV. Interprofessional meetings — (Requirement - 5) i / RD Initials #See checklist 2] ay vader “TC for ae jnitals V. Geriatrie Care: MDS (Minimum: 5 Quarterlies/at least 1 Annual) Date: 2/it quarterly x Reference LTC 217 quarterly Module for 12f17 quarterly these assessments. 2 iq. qvaneriy inf quarterly 12.]i7 Annual —following Care Arca Triggers (CATs) & Care Area Assessments (CAAS) ProtocolsVI. Counseling/ Motivational Interviewing A. 1:1 outpatient nutrition counseling - Provide Preceptor Checklist Form The R.D. should observe a minimum of 4 courseting sessions before will be able to: complete these sessions with minimum supervision. . . 4Gee Education B, Group Education - Provide Lesson Plan and Competency hecklist 1 d Counseling Module w VIN. Quality Management A. QM or PI study Ourvey Diabetic I, Indicator tool used or Issue to investigate: (HJUCOMEHY USe among pati ons 2. Attended a facility wide QM meeting: Dati Monday Feira © Topic: B Pp. Peconing B. Outcome Study (if feasible) - OL/uLomuidir Use aniong Diabetics