It’s nearing the end of the second week and I’m learning so much! Yesterday I performed a diet history with a diabetes patient, and today I did two more. We do this to measure how much they adhere to their prescribed diabetic diet and monitor their blood sugars, use insulin, etc. Using that information, we are better able to make a recommendation on how to improve their health outcome. I was a little nervous at first, but I’m gradually getting a little more comfortable with interviewing patients.
Today I was also able to write two patient notes and enter them into the complex computer system that the hospital has. Unlike where I used to volunteer, this hospital doesn’t write standard notes; they enter data into a sort of database that generates a note for them! It’s extremely efficient if you know what you are doing…which is what I’m working on for now! It takes a while to get used to, but I’m sort of getting the hang of it. Practice makes perfect, right?
There are many parts to a nutrition note: assessment, diagnosis, intervention, and monitoring/evaluation. My job is to scour the doctors’ and nurses’ notes for relevant information such as height, weight, general appearance, diagnosis, past medical history, and medications. Then, I go and speak to the patients about their habits. Next, I make a nutrition diagnosis using the American Dietetic Association standardized language, which for now I have to look up in a book until I become more familiar with it. It goes: “(problem) related to (etiology) as evidenced by (signs/symptoms).” Then I decide what intervention needs to be done, such as their caloric and protein needs, and which kind of hospital diet they should be assigned. Last, I set goals and describe how to monitor them.
It took my whole day to do two patients; by the end of the rotation I’ll be able to do 5-6 complex patients per day! Although we’ve been focusing a lot on diabetes, soon we’ll change the focus to oncology, then to cardiology.