NE: 3 High Risk Care Plans

Effective Date: 07/09 Downloads: PDF Version    Revised Date: 07/14


The development and implementation of an individual care plan is required for all participants identified as high risk, per Nevada State Nutrition Risk Criteria. Nutritionists or Dietitians are allowed to provide high risk counseling.


Nutritionists or Dietitians are the only individuals authorized to provide high risk counseling. Qualifications for nutritionists and dietitians include: 1) Bachelor’s degree in the field of nutrition from an accredited college or university, 2) have the credentials of a Registered Dietitian (R.D.) or eligibility for registration with the American Dietetic Association or 3) have a Master’s or Doctoral degree in the field of nutrition from an accredited college or university.  Special exceptions may be granted by contacting the State Agency.

Nutrition Care Plans will be written for high-risk participants within 60 days of identification of condition. All high-risk care plans will be documented in the Progress Notes or on a High Risk Care Plan form, and placed in each participant’s chart. Local Agencies may utilize the existing care plan forms or develop their own. If the local agency chooses to develop their own they must adhere to the standards below and submit a copy to the State Office.

All documentation must be formatted and include at a minimum the following:

  1. Subjective– Information obtained from the participant and/or participants family/household. Participant’s description of food habits and intake and psychosocial information of the participant. Other facts or opinions related to the interviewer by the participant or sponsor.
  2. Objective- information such as heights, weights, hemoglobin/hematocrit values, other test results, and immunization status. There is no need to repeat information that is included elsewhere in the file.  The statement “See Intake History, Medical Questionnaire”, etc., is sufficient.
  3. Assessment-The staff’s analysis or interpretation of the subjective and objective data about the participant that results in conclusions about his/her nutritional status and nutritional risk. Evaluation of food intake in meeting caloric/nutrient needs. Evaluation of nutrition-related problems, laboratory values. Assessment can also include opinions about the participant/sponsor’s attitude, interest level, likelihood of following suggestions, etc.
  4. Plan -This section should include what has been done concerning:
  • Recommendations based on assessment
  • Specific written instruction, education plans (e.g. diet instruction or sample menus) or recommendations.
  • Materials provided to the participant/sponsor (topics discussed and materials given should be written on the Nutrition Documentation Form and need not be written in the care plan)
  • Goals to achieve behavioral objectives, including how goals will be accomplished and in what time frame.
  • Additional data required, such as plans to redo anthropometric or biochemical measurements.
  • Follow-up plans for subsequent visits for evaluation, referral to other health professionals/agencies, phone contacts and consults with physicians.

The plans should include specific information about who is to complete activities and when. It should be clear enough to allow anyone involved in follow-up to understand how to proceed.

Finally, the care plan must be signed by the Nutritionist or Dietitian.

Telephone Contact

Telephone contacts may be used to provide nutrition education to high risk participants for the following reasons:

  1. To participants who are unable to come to the clinic for medical reasons.
  2. To rural areas that have limited nutritionist availability and long distance travel is not feasible.
  3. To high risk participants who have missed the original face-to-face appointment and rescheduling presents hardship for the participant.

Telephone contacts shall not be used as a substitute for scheduled face-to-face appointments with the nutritionist or be used when current data needed to make an accurate assessment is not available (such as weight, height or hemoglobin values).

The high risk nutritionist/dietitian will:

  • Contact the participant in advance to schedule the appointment for the high risk telephone contact.
  • The Nutritionist/Dietitian will review recent information collected in the chart to review before the telephone contact.
  • Any necessary informational reinforcements such as handouts can be mailed or e-mailed to the participant.
  • Document in the participant file that the high risk care plan was held over the telephone.