“It is All a Part of the Process”

By Linh Nguyen

A former coworker of mine used to say to me, “It is all a part of the process.” I believe those words are a foundational truth that can be applied to almost all aspects of life. My dietetic internship experience started off with my clinical rotation at Sibley Memorial Hospital in northwest Washington, DC. Learning to review a patient’s electronic medical chart, interview the patient, perform an adequate nutrition focused physical exam when necessary, determine the nutrition care process, and finally capture it all succinctly in a note is most certainly an evolving process for me.

Becoming familiar with and adept at utilizing the electronic medical record, Epic, was one of my first important tasks as an intern at Sibley. Overall, I found this cloud-based application to be very customizable and intuitive for users. Fortunately, my preceptor helped configure my Epic account to easily access relevant information and data. Epic stores and displays information in a multitude of ways, and it is just a matter of remembering where and how to access the data you need. I can say learning Epic was the easier aspect of the clinical rotation for me. Learning what pertinent information and data are needed to adequately assess a patient’s status and nutritional needs requires a level of judgement that, with practice, I have developed. Fortunately, my preceptor provided examples of formatted notes that can aid in this process. I initially wrote down a list of information I need on a patient to make sure I am not missing anything, seen here at the bottom, middle part of the picture.

Interviewing the patient and/or family members is another important part of the process. Some patients are easier to interact with than others. I empathize with the fact that many patients are in pain, are scared, do not want to be in the hospital, and are suffering immensely. Other patients are simply unable to physically talk or are not mentally sound so cannot provide adequate information. Still, other patients are happy for the visit and are engaged. In the beginning, I made sure to follow my checklist of information I needed from the patient to ensure I did not miss anything. This approach made me seem undoubtedly robotic to the patients. Observing the preceptors having a conversation with patients while gaining pertinent information helped me see how to interact with patients in a more natural and fluid manner. Over time, the process of interviewing patients has become less effortful and more natural for me. I have become more comfortable gathering the information I need from the patient and believe the interactions are smoother and more comprehensive. Again, this part of the process improved with practice.

The nutrition focused physical exam (NFPE) is an indispensable skill that clinical dietitians need to be comfortable and adept at performing. I was able to perform the NFPE on several patients during this rotation. The first and most important thing about performing an NFPE is gaining the patient’s consent. If a patient would rather not have the NFPE performed on them, I tried to look at the patient from various angles and at different parts of their body to see if I could visually assess for fat and muscle wasting. I typically told the patient what part of their body I would touch before I touch it. A patient’s possible limited mobility, any lines or equipment attached to various parts of the patient, and their body posture in the hospital bed dictates what area of the patient’s body I could assess. Another important aspect of the NFPE is to try to assess what is “normal,” or the baseline body type for a patient before the illness occurred, to be able to determine how the patient’s body has changed over a defined period of time. Documenting evidence and data that are undoubtedly facts about the patient are necessary to diagnose for malnutrition. Two of the resources I used on almost a daily basis are the Nutrition Focused Physical Exam Pocket Guide and the Academy/ASPEN’s criteria to support a diagnosis of malnutrition.

The last part of the nutrition assessment and intervention part of the process is documenting it all in the note. At the start of the rotation, my notes were choppy and not comprehensive. I should have been embarrassed if I knew any better! Throughout the weeks of reading the dietitian’s previous notes and the notes of other healthcare providers, I gained a sense of correct verbiage, acronyms, and data needed to complete a note. I gained a sense of what information I needed to document and in the correct fashion. With time and practice, my note writing skills developed.

Collaborating with other members of the health-care team and revising nutritional needs based on the patient’s clinical course and plan of care are important parts of the process as well. After speaking with the patient, and sometimes the nurse and/or a patient’s family member, I thought I had all the information I needed to create a nutrition care plan and to write the patient’s note. Although, a sudden change in a patient’s plan of care updated from a doctor or nurse may require changing the nutrition intervention as well. (For example, a patient has just been extubated and is no longer receiving propofol, or the doctor no longer plans to initiate tube feeding). It is all a part of the process!

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