Medical Nutrition Therapy Rotation
Acute Care: St. Francis Medical Center
Long Term Care: Elkin's Crest Health &Â Rehabilitation Center
I completed my Acute Care rotation at St. Francis Medical Center (SFMC) in Trenton, NJ. SFMC was founded in 1874 by the Sisters of St. Francis of Philadelphia as Trenton's first hospital. Today, SFMC is an acute care teaching hospital that has over 300 medical staff physicians representing various specialities.
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I completed my Long Term Care rotation at Elkin's Crest Health & Rehabilitation Center located in Elkin's Park, PA. Elkin's Crest is a part of Saber Healthcare Group providing commitment, clinical leadership, and customized care. At Elkin's Crest a variety of senior care services are offered which includes skilled nursing, rehabilitation, and long-term care. They specifically specialize in senior rehabilitation services, cardiac/ stroke recovery, IV therapy, wound care, and more in their 150 bed facility. Interdisciplinary teams collaborate on a daily basis to work on individualizes treatment plans to help individuals reach their highest functional levels.
Module 1 - Introduction
Acute & Long Term Care
At my Acute Care site, I worked with my preceptor and Registered Dietitian at St. Francis Medical Center. There are three dietitians that work at St. Francis. Two of the dietitians are full time and the other dietitian is per diem. This facility operates under Trinity Health. At this location dietitians use Soarian, the electronic medical record.
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At my Long Term Care site, I worked with my preceptor and Registered Dietitian at Elkin's Crest Health & Rehabilitation Center. I also completed work for Broomall Manor, for my preceptor cares for patients at both of these locations. Both facilities operate under Saber Healthcare which is long term senior care and nursing. At both locations I had access to PointClickCare, the electronic medical record.
Below are the remaining modules in my medical nutrition therapy rotations. Module 2 will cover the topics of ethics and professional development, including my health promotion project. Module 3 will focus on nutritional screening and assessment and my case study project will be covered in Module 4. Module 5 will cover the topics of nutrition education and counseling. My Long Term Care and Pediatrics experiences will be included in Module 6. In my last module you will find an overview of my professional practice rotation at St. Francis Medical Center. All of my projects and work are displayed throughout the modules below.
Module 2: Ethics & Professional Development
Professional Development Plan
I completed a student professional development plan (previously known as "Goal Wizard") by going through the CDR's 2021 Essential Practice Competencies PDF. My plan includes three goals that are associated with a competency. For each competency there are three performance indicators. Over the course of my dietetic internship I will be working on completing these goals and competencies.
Academy Meeting Information
I wrote an article for the PAND's spring/summer newsletter. Unfortunately, I was not able to attach the published newsletter. For it is still be edited by the newsletter editor. I have attached a document of the soon to be article for viewing purposes. This meets the criteria for the volunteering portion for my Module 2 checklist.
Health Promotion Project
During my Acute Care rotation I completed a Health Promotion Project on the Mediterranean Diet. I made a poster as well as a shopping list for employees and community members to see. These items were placed around the cafeteria. Interested employees, patients, or family members could take the shopping list to help assist them in their next grocery store adventure. The poster was made into handouts as well for take-home purposes. The handout contained basic information on the Mediterranean Diet as well as a "red, yellow, and green" section. This section provided viewers with things to consider, foods to limit, foods to eat in a visually pleasing format. I also provided education to the dietitians on this subject matter. For the head clinical dietitian was very interested in the Mediterranean Diet.
Module 3: Nutritional Screening & Assessment
Interdisciplinary Care Meetings
Each morning I attended interdisciplinary rounds with the dietitians at St. Francis. The first set of rounds are for 3B and the next set of rounds are for 2A and 2B. Then, every Monday and Thursday the ICU has rounds. The fifth and eight floor do not hold daily rounds. The dietitian, physical therapist, case manager, social worker, pharmacist, Chaplin, physicians, and nurses are typically present for each set of rounds. During rounds, each patient was discussed explaining admission details, significant changes, discharge plans, and medical treatment plans. At rounds, I discussed the patients' nutritional status from a dietitian's perspective. Below are a set of questions that I would typically ask a patient during an interview.
Swallowing Evaluation
Please refer to my LTC section in Module 6 for more information regarding swallowing evaluations.
NCP Documentation
St. Francis Medical Center uses the electronic medical record, Soarian. I completed documentation for full nutrition assessments as well as follow-ups and length of stay assessments. Soarian is not very student friendly, therefore I completed my assessments on a document my preceptor made for interns. He then would review and sign off on my assessments and input the information into Soarian. My LTC site used PointClickCare (PCC) as their electronic medical record. PCC was very easy to navigate and was student friendly. Here, we were able to input all of our notes directly into the medical record and have our preceptor sign off on them from there. Below is the assessment form used by students at my acute care rotation.
Prioritizing Patient Needs
All of the dietitians begin their day by printing the Nutrition List Report for all of the necessary floors for that specific day. They then go through and highlight the patients that need to be seen per a nutrition screening, length of stay for 7+ days, nursing referral, or new Hemodialysis (HD)Â trigger. Follow-ups for "low risk" are 7 days, "moderate risk" are for 5-6 days, and "high risk" are for 2-3 days.
Encounter Forms - Uncomplicated Cases
Please click the button below to view my Uncomplicated Encounter Forms
Encounter Forms - Complicated Cases
Please click the button below to view my Complicated Cases Encounter Forms
Clinical Case Log
Below is my clinical case log for both Uncomplicated Medical Conditions and Complicated Medical Conditions. The date of the note addressing the required medical condition can be found on this log.
Module 3 Checklist
Module 4: Case Study
Case Study Project
I completed my case study on a patient with Crohn's Disease. This patient is a current inmate at a NJ Correctional Facility. The patient has had Crohn's Disease for 20 years and was experiencing a flare-up that included abdominal pain, nausea, vomiting, and bloody diarrhea. My presentation outlines information about the patient, Crohn's Disease, his stay at St. Francis, and his nutritional care. The paper offers a deeper investigation into this case study. Below you will find my preceptor evaluation form.
Case Study PowerPoint
Case Study Paper
Module 5: Education & Counseling
Group Education Lesson Plan
Below you will find the lesson plan for the Group Education which was completed at my LTC rotation at Elkin's Crest Rehabilitation Center. I worked with Monica, who was another Marywood Dietetic Intern.
Group Education Presentation
Below you will find the PowerPoint Presentation put together by Monica and I for the residents at Elkin's Crest during our time in LTC.
Group Education Evaluation
Below you will find my evaluation for my Group Education completed by my LTC preceptor at Elkin's Crest.
Motivational Interviewing
Below you will find my motivational interviewing evaluation which was fulfilled and completed by my preceptor back in my community rotation. Though this is not to take away from the countless motivational interviewing opportunities I've experienced with patients at St. Francis Medical Center.
Module 5 Checklist
Module 6: Long Term Care & Pediatrics
State Inspection
The Department of Health (DOH) state inspectors arrived a few days after my arrival at Elkins Crest Rehabilitation Center. It was a wonderful experience to see the DOH inspect the facility. Unfortunately, the facility received several tags. The first tag was an F0561. The second tag was an F0812. The third tag was F0908. The fourth and final tag was a P2020. The reports from the audit can be found below.
State Inspection Revisit Survey
Because of the tags Elkin's Crest was given, they were required to have the DOH revisit to observe the corrected deficiencies cited on November 17, 2021. The revisit survey was completed on December 10th, 2021. My rotation was over by the time the DOH returned for their revisit survey, though it would have been a wonderful experience to observe this process.
MDS, CAT, & CAA
The Minimum Data Set (MDS) is a Long Term Care screening/ assessment tool used in facilities that participate in Medicare or Medicaid. Throughout my rotation I became very familiar with this form. During my days at Elkins Crest I completed admission, quarterly, and annual MDS forms. The corresponding documentation included either admission assessments (admission MDS), progress notes (quarterly MDS), or annual assessments (annual MDS). My preceptor walked me through how to complete Care Area Assessments (CAA). This helped further investigations of nutrition-related Care Area Triggers (CAT) which would trigger in the annual MDS. CTAs are specific resident responses for one or more MDS element. The triggers help identify residents who are at risk for developing certain functional issues that may need further assessment. CAAs helped determine if interventions and care planning was needed for the patient. Below are examples of MDS admission assessments. I would typical complete 3 to 5 admission or quarterly MDS assessments each day.
Follow Up and Reassessment Documentation
Unfortunately there were no residents due for a MDSÂ annual assessment during my LTC rotation. This is often due to quarterlies overlapping with annual assessments. In this case, this is noted as "ARD" in the Nutrition Monitor and Nutrition Evaluation section of the quarterly assessment to make note that the annual review was due around the same time period as the quarterly. Therefore I used a quarterly that was around the same time as an annual would be due to note any weight, appetite, or diet order change. Below are examples of 5 MDS quarterly assessments I completed during my time at Elkin's Crest and Broomall Manor and the 1 MDS quarterly assessment I used to do a "mock annual" assessment. In these assessments I reported on any 30 and/or 90 day weight change, diet or nutritional support change, consumption change, etc. My preceptor went into great detail about what goes into an annual assessment and the steps to complete one.
Patient Rounds
I had the pleasure of attending meal, medical, and skin care rounds. Medical and skin care rounds often involved an interdisciplinary approach which was available in PointClickCare. In PCC there was a section specially made for wound care notes. These notes had information on each wound, the healing process, and interventions that were taken.
When my preceptor, Amanda Berardi, completed rounds she would add any additional information into PointClickCare where I was able to access and view them. Food preferences as well as likes and dislikes of food were also noted by the dietitian. This helps promote intake by the patient. Communication is crucial in a Long Term Care setting. I was unable to attach rounds information due to the confidential nature of the meetings. Below are a list of daily tasks the LTC dietitian should be completing each day. I found this very helpful when getting myself organized for the day.
Adaptive Eating Devices with OT
My preceptor helped me set up an afternoon of shadowing with the occupational therapist (OT). During my afternoon of shadowing the OT reviews adaptive eating devices with me. There needs to be strong communication between the OT, Speech Language Pathologists, and the RD. This is due to the goal of patient's maintaining their weight and achieving adequate intakes. Adaptive eating devices include plate, bowls, cups, and utensils. I specifically saw the OT use a lipped plate with the patient. A lipped plate has rims to allow for scooping and decreased spillage. I also saw the weighted utensils being utilized. Weighted utensils help patients with tremors. Other adaptive eating devices include double handed cups, proval cups, suction bowls, and partition plates. Occupational therapy requires great attention to detail and unique ways for the patient to achieve greater consumption. Below you will see pictures of the adaptive eating devices I saw being utilized during my shadowing experience.
Menu Design & Modification
My preceptor discussed Elkin's menu design and modification with me. Unfortunately, there was not an opportunity to coordinate menu design and modification due to the menu being set in stone for the year. Elkin's has various therapeutic diets for patients with specific needs. Examples of diets include no salt added (NAS), regular ground, mechanical soft, renal etc. Below is a powerpoint made by me and another intern about the various therapeutic diets Saber has to offer at their facilities. This power point can also be found in Module 5 under Group Education.
IDT Meetings & Nutrition Care Plans
I attended daily IDT meetings with my preceptor at both Elkin's Crest and Broomall Manor. During these meetings important information concerning the patients and their wellbeing. Then, there was a second morning meeting where various department heads came together to discuss important information and news concerning the facility. I also had the opportunity to attend daily rounds in my Acute Care rotation. I was unable to attach meeting minutes due to the confidential nature of the meetings.
Nutrition Support Monitoring & Changes
I completed several progress notes for residents that received enteral feedings during my rotation. Through this, I was able to practice my tube-feeding calculation skills. During this time I became very familiar on how to calculate the calories, protein, free water, and flushes for patients. Upon calculating their needs, I would then compare my findings to the patient's estimated nutritional needs. This was done to determine if their needs were met. All tube-feeding changes were discussed with my preceptor. At all Saber Healthcare Groups Nestle products are used. Isosource 1.5 and Novasource Renal are the two tube feeding formularies used. Mighty Shakes, Resource 2.0, Med Pass 2.0, and Pro-Stat are the oral supplements used. The example below shows the calculations behind a PEG order. This case is unique because the patient needed 90% of his kcals and 100% of his protein met via PEG. A new flush order was also needed. It is very important to monitor potassium, phosphorus, and magnesium levels in the event that re-feeding syndrome would occur.
Resident Referrals
It is very important to refer residents to other interdisciplinary teams when needed. During my time in LTC I saw referrals for speech language pathology (SLP), occupational therapy (OT), and physical therapy (PT). A common example of a referral would be signs and symptoms of swallowing difficulty reported via the patient or my preceptor. This patient would be referred to an SLP for possible dysphagia. The SLP explained the modified barium swallow (MBS) in great detail. She also provided us with a report which can be seen below. The report shows pictures of the patient's eval and notes concerning the outcome.
Long Term Care Checklist
Pediatric Case Study
I was unable to observe a pediatric patient during my time at St. Francis Medical Center. Below you will find my completed the supplemental pediatric case study.
Pediatrics
Professional Practice
I completed my Professional Practice hours at St. Francis Medical Center in Trenton, NJ. Overall, it was a great experience where I was able to serve patients from all different backgrounds. Through the 96 hours of staff relief I was able to receive a competent rating in efficiency, competence, communication skills, and professionalism.
During this time I focused most of my attention on the ICU unit. Here, I was able to strengthen my critical care skills as well as my nutrition support recommendation skills. Many of the patients in the ICU are on nutrition support and frequently needed new recommendations to accommodate their changing health statuses. A critical care dietitian plays an essential role in the ICU and helps improve patient outcome.
