Abstract
With charting by exception, only significant findings or exceptions to the norms are documented in script by the nursing staff. Upon admission, patients are screened for nutrition risk or need for nutrition education by nursing staff using an interdisciplinary patient database. Patients with predetermined criteria indicating nutritional risk or with nutrition education needs are referred to nutrition services. Using specified criteria, the clinical nutrition staff assign referred patients to a level of care. Nutrition care or education is provided and documented within 48 hours. Documentation varies with the level of nutrition care. J Am Diet Assoc. 1997;97(suppl 2):S131–S138.
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