Studies suggest that up to 35% of care home residents are at risk of malnutrition, yet with proper monitoring and intervention, many nutritional problems can be prevented or reversed. This guide covers the documentation needed to support good nutritional care.
Nutritional Assessment on Admission
Every resident should have a comprehensive nutritional assessment on admission. Document:
Current Status
- •Current weight and height
- •BMI calculation
- •Recent weight changes
- •MUST score
- •Visible signs of malnutrition
Dietary History
- •Usual eating patterns
- •Food preferences and dislikes
- •Cultural or religious requirements
- •Allergies and intolerances
- •Previous dietary interventions
Physical Factors
- •Swallowing difficulties
- •Dentition and oral health
- •Mobility affecting eating
- •Dexterity issues
- •Appetite and nausea
Medical Factors
- •Conditions affecting nutrition
- •Medications affecting appetite
- •Dietary restrictions
- •Supplements prescribed
- •Enteral feeding if applicable
The MUST Assessment
The Malnutrition Universal Screening Tool (MUST) should be completed on admission and regularly thereafter. Document:
Step 1: BMI Score
BMI >20 = 0, 18.5-20 = 1, <18.5 = 2
Use alternative measurements if height/weight unavailable.
Step 2: Weight Loss Score
<5% = 0, 5-10% = 1, >10% = 2
Unplanned weight loss in past 3-6 months.
Step 3: Acute Disease Effect
Add 2 if acutely ill and no nutritional intake for >5 days
Or likely to have no intake for >5 days.
Total Score
0 = Low risk, 1 = Medium risk, 2+ = High risk
Document care plan actions based on risk level.
Review Frequency
MUST should be repeated monthly for all residents, weekly for those at medium or high risk, and whenever there's a significant change in condition.
Weight Monitoring
Regular weight monitoring is essential. Document:
- Weight: Actual weight in kg, same scales, same time of day
- Frequency: Monthly minimum, weekly if concerns
- Comparison: Calculate percentage change from previous
- Trends: Graph weights to visualise patterns
- Actions: What was done if weight loss detected
Food and Fluid Charts
For residents at nutritional risk, detailed intake monitoring is essential:
Food Charts
- Record each meal and snack
- Estimate portion consumed (%, quarters)
- Note food refused and reason if known
- Include supplements and fortification
- Calculate daily totals
Fluid Charts
- Record all drinks offered
- Document actual amount consumed
- Include fluids with medications
- Note IV or subcutaneous fluids
- Calculate 24-hour totals
Fluid Targets
Most adults need 1.5-2 litres of fluid daily. Document:
- Individual fluid target (considering medical conditions)
- Preferred drinks and temperatures
- Actual intake vs target
- Signs of dehydration observed
- Actions taken if target not met
Care Plan Documentation
The nutritional care plan should include:
Dietary requirements
Texture modifications, fortification needs, special diets, supplements.
Mealtime support
Level of assistance needed, positioning, equipment required.
Preferences
Favourite foods, portion sizes, eating environment preferences.
Goals
Target weight, intake goals, specific nutritional objectives.
Interventions
Specific actions to address identified risks or problems.
Review dates
When to reassess and evaluate effectiveness of interventions.
Mealtime Documentation
Document mealtime observations to build a picture of eating patterns:
- Appetite and engagement with meals
- Assistance provided and by whom
- Time taken to eat
- Any difficulties observed (chewing, swallowing, fatigue)
- Social interaction during meals
- Environmental factors affecting eating
Swallowing Difficulties (Dysphagia)
If swallowing difficulties are identified, document:
- SALT assessment findings and recommendations
- IDDSI texture level prescribed
- Thickener requirements for fluids
- Positioning requirements
- Signs of aspiration to monitor for
- Staff training completed
Safety Critical
Dysphagia documentation must be prominently displayed and accessible at mealtimes. All staff must know each resident's texture requirements to prevent aspiration.
Referrals and Specialist Input
Document all referrals related to nutrition:
- GP referrals for weight loss or nutritional concerns
- Dietitian assessments and recommendations
- SALT referrals for swallowing assessment
- Dental referrals affecting eating
- Follow-up actions from specialist advice
CQC Expectations
CQC inspectors specifically examine nutrition and hydration. They look for:
- Nutritional screening on admission and regularly thereafter
- Individualised care plans addressing nutritional needs
- Evidence of weight monitoring and action on weight loss
- Appropriate texture modifications and their documentation
- Hydration monitoring for at-risk residents
- Staff knowledge of individual dietary requirements
- Mealtime observations showing person-centred support
Warning Signs to Document
Record and escalate these concerns promptly:
Conclusion
Good nutrition and hydration documentation isn't about ticking boxes—it's about ensuring every resident receives the nutritional support they need. When documentation is thorough and accurate, it enables early identification of problems, guides effective interventions, and demonstrates the quality of nutritional care provided.
The key is consistency: regular assessments, accurate recording, timely action on concerns, and clear communication between all those involved in a resident's nutritional care.
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