NE: 2 Documentation of Nutrition Education
|Effective Date: 05/90||Downloads: PDF Version||Revised Date: 12/15|
Local agencies shall document nutrition education provided to WIC participants to plan and deliver cohesive services to the participant, avoid unnecessary repetition, to make staff aware of the individual needs of the participant and to record goals provided at every appointment.
Qualified CPA and/or nutritionist/dietician staff shall clearly and consistently document all provided nutrition education in the participant’s records. This includes the provision of required program information, notices and program services such as nutrition education, referrals and handouts at every appointment.
Progress Notes can be used to record care plans for high-risk participants and may be used to record any other information. Nutrition Documentation Forms must be used to record all other nutrition education.
Nutrition Documentation Forms
On initial certification, a Nutrition Documentation Form should be started for each participant and included in his/her file. Three forms exist, one for women, one for infants and one for children.
1. The participant’s name, family number, and member number should be recorded on the top of the appropriate form.
2. The person providing the nutrition education should date and write their initials and date of appointment in the space provided in the Date/Staff Initials section.
3. Handouts, pamphlets or other educational materials given to participants must be documented in the Handouts and Class Title section by writing the title of the handout. When offering brochures to complement the nutrition education provided be sure to review the handouts with participants by summarizing the main points. Document the date in the Date/Staff Initial section. An example on the child form follows:
4. Referrals to other agencies or programs should be documented by placing the date in the space preceding the name of the agency. If not listed, the agency/program name should be written in a blank space at the bottom of the list and dated. An example of the women’s form follows:
5. Plans for future nutrition education or counseling/follow-up on existing nutrition related problems should be noted on the Next Steps section of the form.
6. For children there is a separate space on the form dedicated to the Child Health Assessment (CHA). The CPA should use this space to document any anthropometrics and note any significant responses to the four CHA screening questions.
7. When conducting nutrition education appointments be sure to use participants-centered service skills focusing on OARS (Open-ended questions, affirmations, reflections, summarize). Incorporate goal setting into the nutrition education and document participant’s goals on the nutrition education form and inquire and document at each successive contact how progressing is occurring.
8. For cases which do not allow documentation on the Nutrition Documentation Form, contacts must be written in the Progress Notes. Documentation in progress notes should never be used to (1) express opinion (The participant smells like alcohol) or (2) diagnose a condition (the participant acts like they are hypoglycemic).
Progress Notes can be utilized to Document:
- Any pertinent, subjective information about the participant that will provide a higher standard of counselling, including but not limited to: current family or personal problems, living situations, medical problems or medical history information not included in the questionnaire can be listed. This information is usually provided by the participant and is to be documented in third person.
Example: The participant states that she is under a lot of stress because her husband is leaving. She said,” I am worried about the kids.”
- Assessment of current nutritional related problems not expressed as specific nutrition risk codes. For example, if a woman is certified for risk 360-(Other medical conditions), the specific condition could be described.
- Name and title of person writing the notes.
- Each appointment made by the participant/sponsor (including next appointment) and whether or not it was kept.
- The date each time food instruments are issued.