Module 3: Nutritional Screening & Assessment
During my rotation, I completed assigned documentation on various nutrition-related problems and conditions. I managed my caseload by prioritizing patient needs, ensuring that appropriate follow-ups were scheduled and completed. I consistently utilized the Nutrition Care Process (NCP) in my documentation, including developing PES statements to support accurate nutrition diagnoses.
I completed multiple cases using electronic medical records, where I retrieved and documented patient data effectively. I also conducted monitoring activities to track patient progress and made referrals to other healthcare professionals when needed.
Additionally, I had the opportunity to observe a swallowing evaluation, which enhanced my understanding of interdisciplinary care. I participated in multidisciplinary care meetings and contributed to the development of nutrition care plans.
Throughout my rotation, I submitted encounter forms for both uncomplicated and more complex cases, ensuring they met required standards. I followed institutional policies and procedures for all documentation, and I also gained exposure to coding and billing processes. Furthermore, I conducted nutrition-focused physical exams, which helped me strengthen my clinical assessment skills
Modified Barium Swallow (MBS)
I was able to observe a 2 swallowing evaluations in my long term care and acute care rotation. This information is displayed in Module 6. and her you can watch a video for the swallow evaluation at the Wilkes Barre general hospital
Play the Video
Clinical Case log
NCP Documentation
NCP Documentation
During my Medical Nutrition Therapy (MNT) rotation, I completed my clinical training across three medical institutions: Oak Ridge Rehabilitation and Healthcare Center, Guthrie Lourdes Hospital, and Wilkes-Barre General Hospital. Throughout these rotations, I gained experience using different electronic medical record systems, including Epic and Cerner. These platforms allowed me to complete full nutrition assessments, follow-up notes, and monitoring documentation using the Nutrition Care Process (NCP). I learned how to efficiently collect and document patient data, develop PES statements, and create individualized nutrition care plans within each system. Working across multiple EMRs enhanced my adaptability and strengthened my documentation skills, as each system required a slightly different approach. I also worked closely with my preceptors, who reviewed and approved my notes, providing valuable feedback to improve the accuracy and quality of my documentation.
