Writing a Nutrition Care Note

So I totally understand that this blog post may not be super interesting to a lot of people. I know most of the people who read this blog are not necessarily clinical dietitians, but this has been something that has been on my mind. I never thought that I would feel passionately about how you should write a nutrition note for a medical record, but now after being a dietitian for 7 years I have opinions. I didn't want to go into clinical nutrition initially, but after working in a hospital for the past 7 years, I definitely feel strongly about a well documented nutrition note. 


I am not going to go through the whole note writing process, because that is boring to most people, but I do want to touch on the last section - The Nutrition Intervention. This is where you get to write what you did to intervene in the nutrition care of the patient, what goals you have moving forward, what you want to monitor and how you plan on evaluating what you monitor (like your professional opinion on the situation). This section I feel strongly about because it is the one place in your nutrition note, where you get to put on display your nutrition knowledge. It is where you outline how you plan to treat this patient and what you anticipate might transpire in the future. It is where your professional opinion is able to be shared. Lots of times I feel that some RDs just put the minimum information in this section. They just put that the goals are met and what they might like changed. They tend to leave out the part about their professional opinion, they might omit details that better description the nutrition problem listed earlier or they might not share what they anticipate might happen during the next week. That is what I feel like detracts from a well writing nutrition note. 

Example - (1) Diuresis has been as anticipated. Weight was down 1.9% from birth weight. Weight gain goals are ~19g/day.  (2) Infant is on TPN support and we are aiming for 92kcal/kg/day, 4g PRO/kg/day and GIR Of 4-6mg/kg/min. Currently the lipids have been turned off as we work up on enteral nutrition. (3) Infant has been having issues with bilious emesis. Infant does have Gastroesophageal Reflux and will have an upper GI done. Slowly working up on enteral nutrition. Feedings are running continuously to help with tolerance. We are using maternal breastmilk. Encourage and support Mom with pumping. Infant may also get donor breastmilk and this is appropriate as a back up plan through 34 weeks gestation/1500g. Total fluid goals are 130-150mL/kg/day and currently tolerating 142mL/kg/day. Monitor tolerance with feedings and working up on volumes and down on TPN support.

Now if you are not a dietitian, this may not directly apply to you, but this idea about sharing your professional expertise is important for anyone. If there is an avenue through which you can share your career expertise in a specific way in your day to day activities ... you should always take advantage of that chance. Taking the time to thoroughly share that knowledge helps to justify your job and show how you are an important member of the team. I know as a dietitian, I want to be respected and valued as a member of the nutrition care team and how I write my notes plays into that. I know there are similar examples for other jobs. When talking to my husband about writing code for data pipelines that he works with that is something that he can do in a neat and well organized fashion. Taking the time to write "clean code" shows his skills has a computer scientists and shows that he cares about the "product" or code that he creates. 

After going through 4 years of school, a year long unpaid internship and now working for 7 years, you better believe that I am going to highlight my nutrition knowledge in that Intervention section of each and every nutrition note I write! Hopefully this encourages you to find ways to highlight your expertise at your job and take pride in the work that you do!