Nursing Home (Name)

Nursing Home (name)

MEAL INTAKE DOCUMENTATION POLICY & PROCEDURE

POLICY:

Resident food and fluid intake at meals is tallied and trended on a daily basis.

PROCEDURE:

1. Certified Nursing Assistants indicate the amount of each food and fluid item consumed at meals by marking the intake record provided with the resident’s meal.

2. The completed intake records are tallied the following day by the Food and Hydration Aide (FHA) and trended on the FOOD AND FLUID INTAKE TRACKING form.

3. Residents with poor food and/or fluid intake are referred by the FHA to the RD/DTR for reassessment via the WEIGHT, FOOD AND HYDRATION NOTIFICATION form.

4. The FHA also verbally notifies the charge nurse of residents with poor food and/or fluid intake, and this information is noted on the 24-hour report.

5. The RD/DTR assesses residents with poor food intake, makes appropriate recommendations to physicians and updates the resident's plan of care.

6. Residents who do not consume their goal amount for fluid intake at meals are assessed by the RD/DTR for clinical signs and symptoms of dehydration (see SIGNS AND SYMPTOMS OF DEHYDRATION CHECKLIST). The RD/DTR makes appropriate recommendations to physicians and updates the resident's plan of care, which may include putting the resident on "Intake Watch" to track between-meal fluids (FHA is informed that resident is on “Intake Watch” via DIETARY/FHA COMMUNICATION form).

of 2 7. Nursing informs the Food and Hydration Aide and the Registered Dietitian/Diet Technician of residents of physician’s orders regarding: a. fluid restrictions, b. intake and output monitoring, and c. “calorie counts.” Residents for which any of these things have be ordered are also placed on "Intake Watch." The Food and Hydration Aide tallies the amount of fluid consumed at each meal (and between meals) and provides the nurse with the resident’s fluid intake information. The nurse records the resident’s fluid intake on the facility’s I&O form.

8. For all residents on “calorie counts,” the Food and Hydration Aide provides the RD/Diet Technician with the completed meal intake estimation sheets from the previous day. The RD/Diet Technician tallies the relevant information and records the findings in the medical record.