I got to post my first notes today in the electronic medical records! Of course I had some help and they were co-signed, but it felt like an accomplishment. The notes were Initial Nutritional Assessments and I had a normal, a mildly compromised, and a moderately compromised patient. There is a template for almost every note that we write at the hospital, which is extremely helpful, especially since the VA does not use the NCP. They use a different template for patients who are moderately compromised because the RD is required to see moderate and severely compromised patients for a Comprehensive Nutritional Assessment. The diet techs do the initial assessments.

In the morning I went on the floor with the diet tech and we talked with each of the new patients, I got to talk with the three for whom I wrote the notes. Then we went back to the office and assessed them based on the information they provided and the notes from the other health professionals in the electronic medical record. I have been impressed by how quickly the health professionals post their notes in the computer system. After doing most of the assessments we went on meal rounds.

I love meal rounds in the psych ward. I am getting to know the patients and I enjoy their questions, complaints, and food requests. I am really amazed by how much time and energy the VA puts into making sure patients receive the food they want. I don’t know if every hospital is this way or if it is a unique characteristic of VA hospitals, or just of the Salisbury VA. I even ended up cutting a man’s salad and unwrapping his muffins because he asked for assistance, and I couldn’t say no. Another patient helped him open his soup, and another is often seen pushing him in his wheel chair. There are little communities in the psych wards and I have enjoyed being part of them for the past week. Very few of the patients are at high nutritional risk, so unfortunately I do not expect to see them much after Sunday.

On Tuesday I will leave the diet techs and I will be with the RD full time. The RD does not do meal rounds in the communal dinning areas in the psych ward. She visits people individually in their rooms.

I learned more about the computer systems. I entered my own “Event Captures” for the first time, which is how we document the time we spend with patients. I couldn’t do it previously because there was some process that had to be completed before hand. I also learned more about menu planning and how to substitute different items to better meet patient’s desires; I learned how to utilize the fact that we are on a 21-day menu cycle to accommodate patient’s dietary preferences.