Clinical Rotation Log
Date: 9/5/2014-10/9/2014
Location: Online Modules
Activities: Completed clinical modules on- gastrointestinal disorders, cardiovascular disease, diabetes, renal disease, oncology, infectious disease, neurological disorders and dementia, nutrition support, behavioral health, and pediatrics
Comments: These modules were very informative and required me to research topics I was not too familiar with. While I was supposed to complete these modules during the corresponding clincial rotation, I began them as I was delayed starting my community rotation. As I prepare to start my clinical rotation next, I believe I am ready to educate patients on what I have learned.
Learning Objectives Met: CRD 1.2
Hours: 72
Date: 11/11/2014
Location: New York Presbyterian Weill Cornell Medical Center
Activities: Attended 'New Standardized Criteria for Pediatric Malnutrition: From Identification to Coding'; summarized the presentation in a conference report
Comments: This presentation interested me because I spent much time at Hackensack University Medical Center preparing guidelines for the identification of malnutrition. I was unaware of how common hospital malnutrtion was- not just upon admittance but during the length of stay as well. It was during this time that I learned about hospital reimbursement and the importance of proper medical coding. This presentation was detailed and informative despite its relatively short duration (2 hours), interactive (incorporated case studies and quizzes), and made simple by wonderful speakers. On a side note, it was great to see former Hunter classmates at their DI site- NY Presbyterian.
Learning Objectives Met: CRD 4.11
Hours: 4
Date: 1/12/2015-1/16/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Read the Food & Nutrition policy & procedure manual; received flu shot;
toured the facility; met with the clinical nutrition manager to discuss
conduct, responsibilities and schedule; input diet changes; prepared diet manuals for each unit; attended MDS (minimum data set) meeting, discussed
annual and quarterly assessments of residents; familiarized myself with resident charts; attended daily menu meeting in kitchen; completed MDS annual and quarterly assessments, updated progress notes, ICCP (interdisciplinary comprehensive care plan), and education monitoring tool; updated Icomet
Comments: Upon arrival at this 815 bed facility I noticed how outdated the building was both inside and out. I assumed the federal electronic medical record (EMR) mandate applied to all institutions and that the facility would at least be updated in that respect. However, I was informed that this only applies to hospitals. If Coler is making the switch to EMRs it is ever so gradual. Patient information can be found both on the computer and in paper charts which is redundant. While the dietitians may know their patients well I obviously do not; yet I am expected to assess these residents without even seeing them. I have been told repeatedly to base my assessment on the previous one (completed 3 months prior). This does not provide the best care, in my opinion. I spent some time in the kitchen where every morning the kitchen staff (dietary aides) meet to go over the day's menu- Coler implements a cycle menu. I also observed the manager recording daily temepratures of both the hot and cold tray lines. Icomet is a computer program that records assessments from all disciplines. As I learn to use these different monitoring tools it only reinforces how unnecessary it is to chart both on paper and electronically.
Learning Objectives Met: CRD 1.2, CRD 1.3, CRD 2.1, CRD 2.4, CRD 2.10, CRD 3.1a-e, CRD 4.5
Hours: 40
Date: 1/19/2015-1/23/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Familiarized myself with the Food Service Suite- CBORD; completed MDS initial, annual and quarterly assessments, updated progress notes, ICCP, and education monitoring tool; performed meal rounds; observed the use of Cyracom; attended staff/endorsement meeting; input diet changes; attended union meeting; completed PI (performance improvement) on coumadin therapy monitoring
Comments: CBORD is a computer program which allows dietary preferences of the residents to be recorded and used when preparing their meal ticket/tray. It is also used to add or remove supplements from the residents' diet. I would like to spend some more time familiarizing myself with this program as it seemed quite complicated during my first tutorial. Whenever an assessment is performed, the progress notes section of the resident's chart must also be updated to state that the assessment has been completed. The ICCP is also updated at this time which states whether the resident has met the goals set for him/her, in addition to stating that the assessment has been completed. Again, the redundancy. Lastly the education monitoring tool is used to record whether the resident or a family member was educated on the current diet/disease relationship. If the resident is unable to be educated due to poor mental status this is also recorded each time. During meal rounds I spoke to the resident's about the acceptability of their lunch, any gastrointestional or physical (difficulty swallowing/chewing) symptoms they may be experiencing, or any preferences they would like to update such as receiving coffee instead of tea. Since many of the residents are undocumented immigrants the use of Coler's language interpreter service- Cyracom is invaluable to the healthcare team's approach. EVery Wednesday the dietitians have a staff metting to discuss coverage, current projects (i.e. National Nutrition Month), and any other pertinent issues. Attending the union meeting was a good practical experience; I observed workers who voiced either new or recurring issues to the
union representative. The rep was very encouraging of employees to speak freely and reminded them often to know their rights. I completed performance improvement evaluations on coumadin therapy; this is to enusre that it is documented in the progress notes that the resident is on coumadin and also that the resident has been eduacted on its drug/nutrient interaction.
Learning Objectives Met: CRD 1.1, CRD 1.2, CRD 1.3, CRD 2.1, CRD 2.4, CRD 3.1a-e, CRD 3.2, CRD 4.10, CRD 4.4, CRD 4.5, CRD 4.6
Hours: 40
Date: 1/26/2015-1/30/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Completed readmission nutrition assessment, MDS quarterly and annual assessments, updated progress notes, ICCP, and education monitoring tool; attended National Nutrition Month meeting; updated Icomet; prepared meal tickets; attended staff/endorsement meeting
Comments: Every year the dietitians at Coler partake in National Nutrition
Month; this year's theme is "bite into a healthy lifestyle". I was assigned to organize this event. I met with several of the dietitians to discuss my ideas for the 3 hour event and how to stay within budget. Since the theme is such a broad topic I wanted to focus on the three main aspects of a healthy lifestyle- physical activity, diet, and stress management. I was instructed to buy a display board, gather educational materials, and order raffle prizes from AND (the Academy
of Nutrition and Dietetics). In addition to this event I will have to deliver two seperate presentations to the dietitians and the dietary aides in the kitchen. This is an ongoing project that I will work on during my time here at Coler. I spent a day in the ticket office which is located in the kitchen. This is where the resident's meal ticket is printed and given to the dietary aides for preparation on the tray
line. I was instructed to make changes to meal tickets that were requested by the dietitians, I ensured box lunches contained appropriate food items for those patients leaving the premise that day, and I counted the meal tickets in each unit for the next three days as is their protocol.
Learning Objectives Met: CRD 1.2, CRD 1.3, CRD 2.1, CRD 2.2, CRD 2.4, CRD 2.5, CRD 3.1a-e, CRD 4.5, CRD 4.10
Hours: 32
Date: 2/2/2015-2/6/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Attended MDS meeting; completed initial nutrition assessment, MDS quarterly and annual assessments; updated progress notes, ICCP, and education monitoring tools; updated Icomet; performed meal rounds; observed PU (pressure ulcer) rounds; attended breakthrough meeting on the clinical pathway for CHF (congestive heart failure); performed tray assessment; attended campus-wide orientation; completed PI on nutrition diagnoses; attended National Nutrition Month meeting
Comments: The MDS meetings are very helpful in learning about the patients.
Usually the meetings consist of the nurse, doctor, dietitian, and recreation therapist. Interestingly, family members are encouraged to attend the meeting when we are discussing that particular patient. Patients are discussed quarterly and annually; progress notes, ICCPs, and education monitoring tools are updated by all disciplines at this metting. During meal rounds I witnessed a dietitian feeding the residents- something I have not observed any other dietitian do during my time here or during my fieldwork in a hospital. I am still unsure of my thoughts toward this very hands on aproach to our job. I attended PU rounds which included the presence of a PU specialist, a nurse, and the dietitian. These rounds are for those at risk of developing PUs. Learning the different types of cushions for chairs and wheelchairs and the rotation schedule for residents that the nurses must follow to prevent skin breakdown is extremely useful information as I assess nutritional risks/needs. I attended a breakthrough meeting on clinical pathways which discussed the treatment of patients during their length of stay; a representative from each discipline was present as well as members of the board of directors. The purpose of the meeting was to set standards of care for patients with specific diseases- I attended the session on CHF. The clinical manager would like at least one tray assessments to be completed each week. A test tray was ordered and upon its arrival to the unit I took the temperature of each item (i.e., milk, hot beverage, starch, vegetable, entree, dessert). It is difficult to obtain accurate temperatures as I spear carrots and such that may leave the tip of the thermometer exposed to the air. Diets of various consistencies (i.e. soft, pureed etc.) may be easier to measure accurately. Henry J. Carter Nursing Home hosted an all-day orientation for new employees which included those of us from Coler. While I found it to be geared mostly towards nursing, I gained some invaluable experience by learning to properly wash my hands and donning/doffing PPE (personal protective equipment). At the end we were required to take a quiz based on our respective institution's policy and procedure manual; most of the information was new to me and was a great learning tool. The PI on nutrition diagnoses required me to look in residents' charts to assess whether a PES statement was written as of 1/2015- new assessment forms were issued at this time and now require a PES statement for each assessment. At the National Nutrition Month meeting we decided on the raffle prizes to be ordered, agreed on educational materials, and I bought the display board to begin working on next
week.
Learning Objectives Met: CRD 1.1, CRD 1.2, CRD 1.3, CRD 2.1, CRD 2.2, CRD 2.4, CRD 2.5, CRD 2.10, CRD 3.1a-e, CRD 3.2, CRD 4.4, CRD 4.5, CRD 4.6, CRD 4.10
Hours: 40
Date: 2/9/2015-2/13/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Performed tray assessment; attended MDS meeting; completed MDS annual and quarterly assessments; updated progress notes, ICCP, and education monitoring tool; updated monitoring tool with current weights, diets, and supplements; gathered educational materials, completed display board, contacted appropriate personnel to provide free samples, and advertised for National Nutrition Monh; performed meal rounds; attended Town Hall meeting- Food & Nutrition
Comments: Every week I shadow a different dietitian; while they all perform the same function each has their own style of writing notes which challenges me to keep track of these differences and apply them only when necessary. I have commented previously that nutritional assessments are completed using information from the previous one instead of speaking with the resident, which I do not agree with. However, this week in particular while cross referencing with computer program data I noticed how outdated the dietitian's monitoring tool was- she was basing her assessments on diets and supplements that some residents were no longer on. In one extreme case it was noted the resident was on a therapuetic/mechanically altered diet when in actuality he received tube feedings. This is a serious issue that needs to be addressed. National Nutrition Month is coming along- I posted flyers in each unit to advertise the event to the staff; the display board is filled with information regarding the three aspects of a healthy lifestly- diet, physical activity, and stress management; there is plenty of educational materials for individuals to take away with them on healthy eating tips and living with certain conditions/diseases, and Abbott has provided free samples of Glucerna products as well. The Town Hall meeting I attended was established so that the kitchen staff could express their concerns and complaints of the working conditions to members of the board of directors of Sodexo. It was a real eye-opening experience to say the least. I hope for the sake of the entire establishment the staff not only in the kitchen but throughout is provided with the necessary equipment and support that they need to do their jobs and do them well.
Learning Objectives Met: CRD 1.2, CRD 1.3, CRD 2.1, CRD 2.2, CRD 2.4, CRD 2.5, CRD 2.9, CRD 2.10, CRD 2.11, CRD 2.12, CRD 3.1a-e, CRD 3.2, CRD 3.3, CRD 4.5
Hours: 40
Date: 2/16/2015-2/20/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Provided staff coverage on holiday; attended MDS meeting; completed MDS annual and quarterly assessments; updated progress notes, ICCP, and education monitoring tool; attended staff/endorsement meeting; updated CBORD; attended daily huddle; updated monitoring tool; file; performed meal rounds
Comments: This Monday was Presidents' Day so only one dieitian was scheduled to
work. As part of staff coverage we had to physically go to each unit and leave our pager numbers should they need our services. While a phone call may have been sufficient I could see the nurse forgetting to write down our information if she was in the middle of something (as they often are). During the staff/endorsement meeting it was announced that Coler would once again start giving residents a piece
of frosted cake and a card on their tray for birthdays. This thoughtful service is to begin on March 1, 2015; I think that such a small gesture will go a long way with these residents. Daily huddles are now implemented at Coler; it is a short 10 minutes where the entire day's menu is gone over. This will also allow the dietitians to
communicate better with the dietary aides and kitchen staff regarding issues with resident meals including prescribed diets, callbacks, and preferences. For a short period of time I was asked to file nutritional assessments from the past couple of years as per the institution's policy to keep these records for up to 3 years.
Learning Objectives Met: CRD 1.2, CRD 1.3, CRD 2.1, CRD 2.2, CRD 2.4, CRD 2.5, CRD 2.10, CRD 3.1a-e, CRD 3.2, CRD 3.3, CRD 3.4, CRD 3.5, CRD 4.4, CRD 4.5
Hours: 40
Date: 2/2/2015-2/27/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Attended daily huddle; worked on in-service project; attended MDS
meetings; completed MDS quarterly and annual assessments; updated progress notes, ICCP, and education monitoring tool; attended staff/endorsement meeting; completed tray assessment; changed the heading on the Policy & Procedure Manual to reflect the new name of this institution
Comments: We were shown a sample birthday cake for the residents' trays at the huddle; it was more than I expected and I think everyone will be pleased with the feedback. Since the dietitian I was shadowing scheduled a day off I used the time to work on my in-service project. At the end of the month I am required to present to the dietitians and the food service staff separatley on a nutrition topic of my choice. Since I already made a display board for National Nutrition Month-Bite Into A Healthy Lifestlye, I will continue with this theme. During a tray assessment I discovered how difficult it is to keep the hot foods hot and the cold foods cold while these foods reside on the same tray. Although the hot foods were within the correct temperature range, the cold items (milk, juice etc.) were outside of theirs. Rethermalization is a wonderful technology but it is not perfect. I heard that the milk is frozen prior to its placement on residents' trays so that it is the correct temperature by the time it reaches the unit in the rethermalization cart but apparently more/different action is needed. As Coler Goldwater Specialty Hospital is no longer, I have begun changing the heading on the Policy and Procedure Manual to reflect the Coler Campus' new name- Coler Rehabilitation & Nursing Care Center.
Learning Objectives Met: CRD 1.2, CRD 1.3, CRD 1.5, CRD 2.1, CRD 2.4, CRD 3.1a-e, CRD 3.2, CRD 3.4
Hours: 40
Date: 3/2/2015-3/6/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Attended MDS/focus meetings; completed MDS quarterly assessments; updated progress notes, ICCP, and education monitoring tool; attended daily huddle; completed admission assessment; updated residents' food preferences; sent out staff coverage e-mail; attended staff/endorsement meeting; worked on in-service project; performed meal rounds; updated monitoring tool; organize unit cardexes; used Cyracom
Comments: Focus meetings are held when there is an important/recurrig incident with a resident; this week several resident's were discussed on account of multiple falls, leaving the facility without a pass, and a positive toxicology result for drug use. This experience allowed me a more realistic view of the problems staff members face when it comes to unabiding residents and the way in which these conflicts of personal safety are handled. Upon assessing a new resident I was disheartened to see the diet prescription already completed by the MD. Without the ability to prescribe diets I do not see the value of this profession. A dietitian transferred from Coler to Henry J. Carter last week; the dietitian who will now be covering those units asked me to organize the binder (cardex) which hold each residents' past assessments. I have been appalled by the lack of organizational skills I have observed including finding discharged patients' information still circulating the facility. I attempted to use the language interpretor service, Cyracom, to speak with a Russian resident. After a brief introduction conducted by the interpretor on the phone it was apparent that the resident was cognitively impaired and could not be educated as she was speaking of random things not related to what I had asked. Cyracom and other interpetor services are a great asset to nutrition education that I hope to one day employ successfully.
Learning Objectives Met: CRD 1.2, CRD 1.3, CRD 1.4, CRD 1.5, CRD 2.1, CRD 2.2, CRD 2.4, CRD 2.5, CRD 2.6, CRD 2.7, CRD 2.10, CRD 2.11, CRD 3.1a-e, CRD 3.2, CRD 4.4, CRD 4.5
Hours: 40
Date: 3/9/2015-3/13/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Attended daily huddle; observed nutrition education; attended MDS meeting; completed MDS annual and quarterly assessments; updated progress notes, ICCP, and education monitoring tool; performed meal rounds; updated monitoring tool; worked on Nutrition Month project
Comments: This week I was assigned to the dementia units. I found these units to be different from other units in that all residents eat together in the dinning room (most other residents eat in their rooms) so that they can be more easily supervised by nursing. Also, these residents cannot be educated. The dietitians approach to nutrition education for these units included coloring in pictures of fruits and vegetables or using flashcards to see if the residents could identify the pictures of foods on them- this also served as an opportunity to update food preferences. Meal rounds for this unit was based soley on observation as most residents cannot communicate well.
Learning Objectives Met: CRD 1.2, CRD 1.5, CRD 2.1, CRD 2.2, CRD 2.5, CRD 2.9, CRD 2.10, CRD 2.11, CRD 3.1a-e, CRD 4.4, CRD 4.5
Hours: 32
Date: 3/16/2015-3/20/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Attended daily huddle; completed MDS quarterly and initial assessments, completed readmission note; attended MDS meetings; updated progress notes, ICCP, and education monitoring tool; completed tube feeding note; performed meal rounds; submitted diet request changes; attended staff/endorsement meeting; presented in-service project; attended continuing education class; updated Icomet; attended
union meeting; performed diet analysis
Comments: The kitchen served corned beef, steamed cabbage, parsley potatoes, and a giant white and green cookie (or lime jello) in celebration of St. Patrick's day this week. As per the meal rounds I completed on three units, the festive dish went over well with most residents. Such little things excite these residents and it's wonderful to witness; I would like to see more variations from the menu cycle as residents tire of the selection easily. At the staff/endorsement meeting I presented my in-service project which coincided with the National Nutrition Month theme- "Bite Into A Healthy Lifestyle". The delivery of the presentation was challenged by first being kicked out of the reserved conference room and then by not having a screen to project my presentation in the new location. I had print-outs of the PowerPoint
for all to follow along but I had to read of my printout more than I would have liked since I wasn't able to simply glance at a big screen. I am scheduled to deliver this presentation two more times to the kitchen staff next week- I hope the amenities are better. An Abbott specialist came to the facility for a continuing education class on 'Managing Hospital Malnutrition'. The topic was not exactly geared toward the population at this facility but it was still informative/interesting, especially since I gave a similar presentation to my seminar class about my fieldwork experience last
year. I was provided a new learning experience this week when I was asked to analyze four units of residents with dementia currently on therapeutic diets to determine not only the percentage of residents on therapeutic diets but also the percentage of those diets that could be liberalized and the percentage of diets that were already changed. No doubt there is a financial gain behind liberalizing diets but it is also beneficial to the residents who may not be experiencing any change in health status despite diet restrictions. At this point in their life/illness why limit certain foods that may be one of the only choices and/or joys that they have left?
Learning Objectives Met: CRD 1.1, CRD 1.2, CRD 1.3, CRD 1.4, CRD 1.5, CRD 2.1, CRD 2.2, CRD 2.3, CRD 2.8, CRD 2.9, CRD 2.10, CRD 2.11, CRD 3.1a-e, CRD 3.2, CRD
3.3, CRD 3.4, CRD 4.4, CRD 4.5
Hours: 40
Date: 3/23/2015-3/27/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Attended daily huddle; compiled overview reports; attended MDS and
focus meetings; completed MDS quarterly and annual assessments; attended meeting on diet liberalization protocol; managed National Nutrition Month fair; presented in-service project to kitchen staff; PI on pressure ulcer status
Comments: I was asked to submit overview reports on two topics- diet liberalization and snack programs. The facility is interested in liberalizing the diets of dementia residents as well as introducing a snack program for residents with inadequate PO intake. I attended a meeting of dietitians and nursing staff regarding the potential protocol for diet liberalization. Unfortunately since my rotation at Coler ends next week I will not be able to see these projects through. However, these assignments were a refreshing break from nutritional assessments. The National Nutrition Month fair went over extremely well; nearly 100 employees stopped at our table to receive nutrition advice, pick up educational materials, and try some healthy snacks. There was literature available for just about any disease or condition (in English and Spanish), raffle tickets and quizzes for a chance to win several prizes (baskets filled with healthy foods and items from the Academy of Nutrition and Dietetics catalog), and fruit, pretzels, and couscous, as well as Glucerna and Splenda products (for diabetics). I presented the PowerPoint presentation ("Bite Into A Healthy Lifestyle") to two shifts of the kitchen staff; while I was unable to use my flash drive in the facility's computer and there was no internet access, I used the display board I made for the National Nutrition Month fair during the presentation for some visual stimulation.
Learning Objectives Met: CRD 1.1, CRD 1.2, CRD 1.3, CRD 1.4, CRD 1.5, CRD 2.1, CRD 2.2, CRD 2.3, CRD 2.4, CRD 2.5, CRD 2.8, CRD 2.9, CRD 2.10, CRD 2.11, CRD 3.1a-e, CRD 3.2, CRD 3.3, CRD 3.4, CRD 3.5, CRD 4.2, CRD 4.4, CRD 4.5, CRD 4.10
Hours: 38
Date: 3/30/2015-4/3/2015
Location: Coler Rehabilitation and Nursing Care Center
Activities: Attended daily huddle; completed MDS initial, quarterly and annual assessments; attended MDS meetings; wrote description of National Nutrition Month fair; updated Icomet; attended endorsement meeting
Comments: I have gained much confidence in my ability to assess the nutritional needs of residents during my clinical rotation. As this is a long term care facility I found the quarterly MDS assessments redundant since the status of these residents do not change drastically. While initial assessments prove more interesting, it is challenging to decipher the handwriting of all the disciplines used to perform an accurate nutritional assessment which is rather frustrating. Since our event last week was such a success I was asked to write a description of our National Nutrition Month fair for 'From Our Heart', which is a publication for employees, patients, residents, and friends of Coler Rehabilitation & Nursing Care Center and Henry J.
Carter Specialty Hospital & Nursing Facility.
Learning Objectives Met: CRD 1.2, CRD 1.3, CRD 2.1, CRD 2.2, CRD 2.5, CRD 2.9, CRD 2.10, CRD 2.11, CRD 3.1a-e, CRD 3.2, CRD 4.5
Hours: 40
Total Hours Completed: 538