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Date:

High Risk Secondary Education & Documentation

GA WIC

August WIC Conference

Barbara Stahnke & Julianne Gaston

August, 2015

GA WIC

Objectives:

Participants will be able to:

1.) Utilize Nutrition Care Process to provide and document High Risk Secondary Education.

2.) Identify targeted questions to increase efficiency and effectiveness in conducting the WIC High Risk Secondary Education.

3.) Utilize SOAP/ADIME notes to completely and accurately document the High Risk Secondary Education to meet WIC High Risk Secondary Ed requirements.

Why do you Document?

• If you didn’t document it – you didn’t do it.• Because I have to• To improve participant care and coordination• To improve program integrity and service delivery

Documentation – Good or Bad?

S- Participant is angry about the delay in service; she is swearing in the clinic; she did not bring an MDF or any formula back for a new formula; she has made a complaint to my supervisor that we would not help her. She wants a new formula for her baby who is crying and not tolerating the current formula

O- H/R 141, 142, 135

A – Invalid complaint because participant does not have the appropriate information or formula

P- Wait for MDF and returned formula and then make the exchange.

Documentation – Good

S- Participant is angry about the delay in service. Mom would like a new formula for her baby who is crying and not tolerating the current formula; did not bring WIC ID folder to visit; has not seen MD; has 4 cans of formula at home

O- Prematurity, Low Birth Weight, Inadequate Growth (HR)

A – Infant at risk for ongoing growth c/o. Potential formula intolerance; however, would benefit from medical advisement; unable to counsel at clinic visit because mom upset.

P- Remain available for ongoing service delivery

Not for Documentation

• Personal Opinion• Disagreements with other providers• Complaints

Academy of Nutrition & Dietetics (AND) SOP and SOPP

Remember to follow Nutrition Care Process in all things related to Practice

Nutrition Care Process

Assessment (Certification is the first step; the high risk visit provides for in-depth evaluation,

counseling and education)

Diagnosis (What is the problem? Why are we doing a high risk visit?)

Intervention (What did you do for and with the participant?)

Monitoring/Evaluation (What is your follow-up plan?)

• ongoing process utilizing multiple tools as appropriate for the client within their community and family

• includes A, B, C, D

• requires critical thinking

• is client focused

• is evidenced based

• includes appropriate documentation

Leads to DIAGNOSIS

Assessment

DIAGNOSIS

DIAGNOSIS – • a process of organizing, analyzing and synthesizing the

assessment information into a nutrition focused diagnosis for the client

• revised and updated as new information is obtained or attained

• includes appropriate documentation

Leads to the planned Intervention

INTERVENTION

• action step

• must be related to the diagnosis and assessment

• planned education, counseling, or activities that will lead to positive changes in the patient’s nutrition risk

– evidenced based

– dynamic

– includes goal setting with the client

– includes a follow-up plan

• includes appropriate documentation

Leads to Monitoring/Evaluation

MONITORING/EVALUATION

• ongoing assessment of nutrition risk (s), outcomes, and progress (comparisons made to goals established)

• identification of new nutrition risk (s)

• critically evaluates the care process for the client

• includes appropriate documentation

High Risk Secondary Education

What do you see throughout all the steps of the Nutrition Care Process?

How do you see this in comparison to your current WIC processes?

GA WIC Minimum Standards - High Risk Contact

SOAP ADIME

Subjective AssessmentObjective DiagnosisAssessment InterventionPlan Monitoring

Evaluation

Two Approved Documentation Formats

High Risk Care Plan

• Tell the participant’s “story”• What happened at the visit

• What is happening next

Targeted Questions for High Risk Efficiency

• What are the High Risk Reasons?• What was the goal?• Was everything captured at the certification?• Overall growth –what does it look like?• How has the participant’s situation changed over time

(may be from documentation history or from recall)?• Does the client recall their goal? • How does the client feel about WIC?

Targeted Questions for High Risk Efficiency

• Are they on a non-contract or special formulas (exempt formulas and WIC Nutritionals)?

• Have they missed visits?• Is the MDF current?• Did the Nutrition Assistant or WIC Clerk give you

some information that is important to evaluate?• Specific questions by type like for BF – were they

having problems, how are they nursing, did they have c-section?

Prioritize• Focus

– Based on Client need and concerns brought up in the visit– Identified Risk– History in WIC– What is the clinic like today?

• Short staffed• High Show rate

• Remember you are “fishing” for information – throw out a lure and see what get.

• USE YOUR Critical Thinking Skills

TX Planning Appropriate Referrals Made

• Children’s First– Copy of referral in chart?– Documented in notes?

• Physician/Specialist– Growth and development concerns

Tx Planning - Issuance Matches Medical Documentation -

Formula

• Was the correct formula issued?– Infant vs junior– Regular vs fiber

• Was the amount prescribed on the MDF the amount issued?– For fully formula fed infants – always issue max allowed– For children – issue only amount prescribed (up to max)

TX Planning Issuance Matches Medical Documentation -

Food

• Did the food portion of the package assigned match MDF?

• If a 999 food package issued were the correct voucher codes used?

TX Planning - Food Package Changes Adjusted Correctly

Documentation - Food

• If vouchers returned, were they voided?– Never delete history

• If formula returned, was the correct amount of new formula issued?

• If issued from stock was it documented correctly in formula log? Was tracking voucher issued?

• Was food package issuance updated at cert?

GA WIC Minimum Standards - High Risk Contact

1.) Was a high risk contact recorded?

2.) Does your note tell the story? (It can be a short story)

Subjective* Are they tolerating formula?How much formula are they consuming?What is happening with their weight?What is happening with their hgb?

Objective List the reason for the High Risk Contact

Assessment Evaluation of subjective & objective needed for High Risk

Plan What education/counseling was provided?Follow-up plan

*These are examples and not an all-inclusive list

GA WIC Minimum Standards - High Risk Contact

1.) Was a high risk contact recorded?

2.) Does your note tell the story? (It can be a short story)

Assessment* Are they tolerating formula?How much formula are they consuming?What is happening with their weight?Evaluation of the necessary information for the high risk visit

Diagnosis List the reason for the High Risk Contact

Intervention What education/counseling was provided?

Monitoring/Evaluation Did they meet their goal?Follow-up plan

*These are examples and not an all-inclusive list

LBW/Premature Infant

• Male certified at 3 weeks old• Born at 35 weeks gestation• Birth Weight: 5 lb 4 oz Birth Length: 18 inch• Weight: 7 lb 1 oz (10th) Length 19.5 inch (5th) actual • Risks identified: LBW, Prematurity• Breastfeeding for one half of the feedings• MDF for Neosure, assigned MBF max package

LBW/Premature Infant

Focus

High Risk follow-up at 3.5 months

I obtained the anthropometrics for follow-up on High Risk Low Birth Weight

Weight: 11 lb 4 oz (< 5th) Length: 23.5 inches (10-25th); wgt/length (10th) actual

Document

Practice writing a brief SOAP note (the story).

High Risk Follow-up Documentation

S- Breastfeeding every 2-3 hours for an hour at a time. Baby is falling asleep during many of these hour long feedings. 16 ounces of formula per day; mom wants to keep breastfeeding but is getting discouraged.

O- Wt= 11 lb 4 oz; Length = 23.5 inches HR LBWA – Inadequate Growth for infant with catch-up growth needs. Main problem appears to be breastfeeding problems related to formula intake leading to decreased breastmilk supply. Mom is in action stage for improving breastmilk supply.

P- Counseled on offering breast first and on infant feeding cues.

Referred to a Peer Counselor for ongoing support.

Discussion and Questions