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I began working on Module 3’s Checklist: Nutrition Screening and

Assessment immediately upon the start of my Acute Care rotation at Grand View
Hospital (GVH) in Sellersville, PA. In order to complete this checklist there are 12
tasks at hand that were easier to check off my list than I had anticipated.
The first item on the list states ‘completed assigned documentation on
nutrition related problems and conditions’. Thus far, I have spent my time at GVH
rotating between 2 of their dietitians and each week I am both learning and working
on different tasks. What they each assign me has been different and varies from
completing my charting on patients, providing nutrition education, researching
certain diseases or lab values and interviewing patients. One example provided in
my portfolio is a handout I created explaining Multiple Endocrine Neoplasia
Syndrome (MENS). After meeting a patient who we considered to be a mystery one
conclusion that was made by the physician was that she could be experiencing
MENS. Neither the dietitian nor I quite understood this disease, which led me to
complete additional research and create the handout.
Next, ‘coordinated her caseload based on priority of need for patients
residents assessed and ensure that appropriate follow up is achieved’. I was unable
to find a way to show proof of my completion of this assignment, however I am able
to describe them. For example, when I work with the Dietitian, Kristi, we are
responsible for attending ICU rounds at 9 am. With that in mind we always start the
day by charting and reviewing information on ICU patients when we know we’re
going to be seeing them first in the day. In addition, if there are patients who may
be scheduled for discharge later in the day we may seek them out earlier in the
morning for their consult or to provide nutrition education to avoid the risk of
missing them before they leave.
Then, ‘completed documentation utilizing the Nutrition Care Process (NCP),
including the development of the PES statements’. Every day when charting on
patients in the EMR components of the NCP are utilized and PES statements are
conducted to assess the patients and their progress during their hospital stays. As
evidenced by the various charts I have uploaded, including those to fulfill the next
requirement ‘complete a minimum of 5 cases/documentation using electronic data
retrieval and storage’, in this module you can see the Nutrition Assessment,
Diagnosis, Intervention, Monitoring and Evaluation.
Next, ‘conducted monitoring services’. Monitoring patients happens often,
typically every 2-5 days in addition to our consultation with them upon admission.
Examples include ordering supplements and monitoring their consumption to make
sure patients are both receiving and accepting the supplement, follow ups to check
intake or education status or monitoring their diet change and how they may be
accepting that as well. Examples of supplement follow up and consultation follow
up are included in this module.
Also, ‘referred patients residents to other professionals as case required’. I
found this occurring more often during the long-term care portion of my rotation
where I was able to complete a Speech Referral form included in Module 6. Often
times at GVH the dietitians are not solely responsible for referrals but it is more of a
collaborative effort with other disciplines to decide what is best for the patients.
One example during my time at GVH is every Thursday afternoon we attend an
interdisciplinary meeting to review, assess and make recommendations for the
rehab patients where each department has the opportunity to share their input. A
common referral that does occur is to the Speech Language Pathologist and I was
able to work with her one afternoon and observe a swallowing evaluation on one of
the patients I was following.
Next, ‘participated in the development of the nutritional care plan for the
multidisciplinary care meetings’. I found myself more involved in multidisciplinary
meetings while working in LTC however, as previously mentioned nutritional care
plans are assessed and reviewed every week during the rehab meetings.
I have also included ‘acceptable encounter forms for 15 uncomplicated cases’
and ‘5 complicated cases’. These cases are patients I have seen during my time at
GVH, my notes on their conditions, comments, PES statements and monitoring and
evaluation plans moving forwards. The interesting part of this requirement was it
forced me to take on more intricate and unique cases per the list of complicated
cases. I found I had no issues assembling my 15 uncomplicated cases and as my
caseload picked up I was able to pick and choose those I wanted to display for my
portfolio. All 20 cases are uploaded in this module.
Lastly, during my first week of the Acute portion of my clinical rotations I
both ‘completed documentation as per institutions [GVH] Policy and Procedures’
and ‘reviewed coding and billing procedures’ with the Clinical Director. The Policy
and Procedures are often referenced on a day to day basis in the inpatient setting
however, the coding and billing procedures are not something I encounter too often
or affect my work as they are more applicable to the outpatient setting. Even
though I am not able to work in an outpatient setting during my time at GVH I look
forward to gaining some of the experience in the future.

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