Nutrition Care Plans: How Do I Build One?

Check off another box for ‘What Dietitians are never trained on.’  Nutrition Care Plans are absolutely essential for the health of our patients.  Yet Dietitians don’t get full training on how to build one.  

Or better yet, what is a nutrition care plan?

Here you will find an explanation of nutrition care plans and exactly how to build them.  The benefit of this article is I have written nutrition care plans for over 7 years!  

What are Nutrition Care Plans?

Nutrition Care Plans are instructions on EXACTLY how someone manages the nutrition care of your patient.

Nutrition Care Plans are a part of the overall care plan for your patient.  Every patient will have a care plan written on them that details exactly how to care for them.  All health care disciplines will help to build it. 

Every discipline is expected to keep their part up to date and specific to the patient.  You will have deadlines to meet and depending on your caseload, it can take some time.

We are going to be releasing basic nutrition care plans (for free!) for those on our email subscription list.  If you aren’t on it, I suggest signing up!  You’ll get it as soon as we’re done.

Now back to nutrition care plans.

If someone reads your nutrition care plan they should know DETAILS of:

1. What is the patient’s Nutrition Diagnosis/Nutrition Problem?

2. What are the patient’s Nutrition Goals?

3. What are the patient’s Nutrition Interventions to deal with the specific Nutrition Diagnosis/Nutrition Problem?

If someone who has never helped that patient comes in, they should be able to read it and know exactly from the moment that patient wakes up until they go to sleep, what they need.

Nutrition Care Process
versus
Nutrition Care Plans

There is not a significant difference between the two.

The nutrition care process is what you are writing in your nutrition assessment form and documenting in the ADIME format in the chart.  The nutrition care plan is in the MDS computer system and printed off. 

The nutrition care plan is a living document that is always being updated.

You will essentially be transcribing the nutrition care process that you have for the patient and putting it into the nutrition care plan.

The nutrition care plan is a summary of the nutrition care process.  If you look at it this way, your nutrition care plan for your patient shouldn’t take long.

This is why I believe that you can have basic care plans built and then just individualise it for the patient.

When a Surveyor or Auditor comes into your facility, they will always read the care plans.  

In the care plan they want to see:

  1. It is individualised.  It helps to put the patient’s name in it.  
  2. The nutrition problem/nutrition diagnosis has been identified.  Nutrition diagnoses are typically done using standardised language (I prefer this way because it keeps it easy to identify). 
  3. The nutrition goals are specific to the patient.  You will put in specific numbers, anthropometrics that are for that patient only.  These should be realistic goals. 
  4. There are identified nutrition interventions to address the nutrition diagnosis/nutrition problem.  There should also be specific nutrition interventions with timelines as to how these will be measured.

When you review your nutrition care plan, look at it through the eyes of someone assessing it.  

What is the Nutrition Diagnosis
/Nutrition Problem

You can use standardised language for the nutrition diagnosis/nutrition problem.  You may hear from some Dietitians that you don’t need to use it, and sure, it’s not a requirement.  But it will make it SO much easier. 

This should be very simple because if you have gone through the nutrition care process, you will already have documentation of the nutrition diagnosis.

In the care plan, just write out what the nutrition diagnosis is.  The nutrition diagnosis, just like in the nutrition care process, is what you are going to be addressing with your nutrition interventions.

Don’t write about a nutrition problem such as weight loss and then write interventions about their Diabetes.  That doesn’t make sense.

You can have a separate diagnosis for Diabetes.  Your care plan should flow and it should be easy to understand.

Building Nutrition Goals

Your nutrition care process documentation will come in really handy here like I said.

What nutrition goals did you and the patient set?  Based on the nutrition diagnosis/nutrition problem.  

Setting nutrition goals should be SMART goals.  

DON’T Write: “Patient will gain weight.”…That is not a nutrition goal!

DO Write: “Mrs. Smith will maintain her body weight at BMI 24.4 (64.4 kg) which falls in a normal BMI range between 23.0-29.9 (60 kg – 84.4kg).  

You can see here that it is specific to Mrs. Smith, it has identified her name, her weight, her normal range, etc.

If you don’t want to consistently be updating the numbers, you could write:

“Mrs. Smith will maintain her body weight within a normal BMI range 23.0-29.9 (60 kg-84.4kg).”

Both are still specific to her and have measurable anthropometrics, but the second one, you don’t constantly need to go in to change the weight and BMI based on when it changes.  

I typically go with the second option and haven’t been corrected on it.

You can also have multiple nutrition goals for one nutrition problem.  You don’t need to go overboard.  If you feel that 1-2 nutrition goals accurately cover a nutrition diagnosis, that’s okay.  

Check out this article for a nutrition care plan example with multiple nutrition goals.  

Building Nutrition Interventions

You SHOULD have multiple nutrition interventions in your nutrition care plan.

If it’s weight loss, multiple nutrition intervention ideas can be found here.  

The nutrition interventions will not only encompass food and fluid prescriptions you have written.  They will also include how the nutrition interventions are going to be measured.  

Another example would be nutrition interventions for Dysphagia.  Your nutrition interventions would include not only modifying the food and fluid texture.  

They would also be measuring whether they’re working.  This can be done through a meal time observation.  

If you want a good meal observation audit, click here for a free one you can use.  

How Do I Put it All Together?

nutrition care plans framework
The Nutrition Care Plans Framework

There will be 3 separate sections that you will fill out.  

You will state the nutrition problem/nutrition diagnosis in the first area.

You will then put in the nutrition goals.  These will likely be separate entries based on the computer system you are working on.

You will also put in the nutrition interventions, again depending on the computer, these will likely be separate entries as well.

In some facilities you are required to enter in the health care discipline that is responsible for each nutrition intervention.  Ask if this is something you need to do.

You will not enter the Dietitian as the individual responsible for each intervention.  If the prescription is to measure their weight on the first bath day of the month, it’s not the Dietitian’s job.  This would be a health care aide.

Make sure you put accurately who is responsible for each, typically it will be the Nurse or Health Care Aide.  

Once you have put all of that into your care plan for nutrition, you’re almost done!

Do Nutrition Care Plans Need Updating?

Yes!

A care plan for nutrition needs updating anytime there is a change in their nutrition care.

The way the care plan is updated will vary from facility to facility.  If there is a hard copy of the care plan, some facilities will ask you to write in the care plan any changes between printing dates.

A printing date is sometimes quarterly when the care plan update happens.  The nurses will reprint and put the new care plan into a binder or the patient’s room.

Between the printing dates, you can update both in the computer system and the paper copy.

Ask at your facility what the policy is in regards to updating the nutrition care plan.  This is a MUST DO.  If a Surveyor or Auditor comes in for a surprise visit, they are expecting that the care plans are always up to date.

Closing Thoughts

A nutrition care plan is a document that you want to make sure is always up to date.  It is essential that you know the guidelines you need to follow.

If you want to read more on nutrition care plans, here is a great nutrition care plan example!  And there’s more to come!

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Michelle Saari is a Registered Dietitian based in Canada. She has a Master's Degree in Human Nutritional Sciences and is a passionate advocate for spreading easy to understand, reliable, and trustworthy nutrition information. She is currently a full time online entrepreneur with two nutrition focused websites.

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