PEIA DatabaseRD Documentation and Use

What’s in it for me??

Home Page

◦ Once you have logged in, your home page will give you a participant search function.

◦ Can search participants with SSN or last name

◦ Can also click on “participant list” in the upper left hand corner and type in first/last name and search by location.

PEIA Weight Management Database

Upper left hand corner will have a drop down menu of resources:

Announcement list: ◦ Provides a list of all announcements that have

been posted.

Contact list:◦ Provides contact information for administrative

staff for the Weight Management Program.

Menu: Resources

Document List

◦ Weight Management Policy

◦ PEIA RD phone based counseling policy

◦ Weight Management User Manual

◦ Weight Management fee schedule

Resources

Report List:

◦ Active Participants by Location: Participant information and program dates

◦ Visits by Date and Location: view consult dates in a specified time period.

◦ Missing Consult Report by Location: This can be sorted by professional.

Resources

Web Link List

◦ Map My Fitness

◦ Weight Management Program Information

◦ Weight Management Resource Page

◦ My Fitness Pal

Resources

Participant Information◦ Address and contact info for the participant

◦ To view complete info including email and birthdate, click on “view participant information” on the upper right tool bar.

◦ On this tool bar you are also able to print the page by clicking “print page”

PEIA Database

Participant Summary page

◦ When you have found your participant in your search, you can pull up their participant summary page by clicking on “summary” to the right of their name.

◦ Contains documentation from all professionals involved, measurements and detailed participant information.

PEIA Database

Participant Summary Page

◦ Status of the participant on the right hand side: what attempt of the program they are in (attempt 1 or attempt 2)

◦ Location of the participant◦ Follow Ups (flags): Here you can send a follow up

to someone or respond to follow ups that have been sent to you.

◦ Blood Work: This will provide the client’s initial lab work if it is available.

PEIA Database

Administrative Notes:

◦ These are notes entered by any weight management staff that update any pertinent information about the participants status and/or progress.

◦ Frequently see updated information on active or hold status, client progress in regards to probation, or issues the facility may be having with participant contact

◦ You can add a new admin note by clicking “new” on the lower right of the page under Administrative Notes.

◦ This area also includes the intake survey data for your review.

PEIA Database

Monthly Measurement Reports

Here you will see monthly measurements taken by the facility staff

Date Weight BMI BP Body Fat % Waist circumference # of facility visits You can view the full report by clicking “view” on the

right- this will include height.

PEIA Database

Care Management Notes

◦ These are notes entered by the participant’s Health Behavior Counselor addressing any relevant behavioral information or successes/barriers related to their overall program- diet, exercise and overall suggestions.

◦ These can be very useful in our overall strategies with clients

PEIA Database

Enter date of service and minutes

History: Client hx (medical/health hx,biochemical and anthropometric data, meds/supplements, wt hx, social/personal hx, dieting hx)

Assessment: Analysis of anthropometric and biochemical data, analysis of baseline food and nutrition hx gathered during interview including diet hx and behaviors regarding eating, food selection and preparation, determination of nutritional requirements/energy balance

Dietitian Encounters

Assessment Continued: physical activity, food availability, assessment of client’s knowledge base, nutrition related challenges, motivation level and confidence/readiness to change.

Nutrition Dx/Notes: Identify/update Nutrition Dx using PES statement (Problem, Etiology, Signs and Symptoms identified).

Dietitian Encounters

Education/Interventions: Identify nutrition prescription, nutrition education, interventions related to food/nutrient modifications, counseling, strategies to overcome barriers, materials and resources used, referrals made

Plan/Goals: Specify goals set/expected outcomes, indicators and methods of monitoring. Identify goals and progress upon follow up. May indicate when follow up scheduled/anticipated.

Dietitian Encounters

Exercise Physiologist and Personal Training Encounters

◦ Here you will see results of EP fitness testing, as well as exercise plan, goals and progress.

◦ Personal Training encounters/minutes are entered

PEIA Database

What do I do if here are issues with clients that need addressed?◦ Follow ups:

Click “new” under follow up Assign to appropriate staff member Indicate follow up type/status Set follow up date Enter an opening note summarizing info needed for

follow up Click “save” You can view follow ups by clicking “view”

Follow Ups

◦ Follow ups can be used to send notes to Weight Management staff for follow up on client requests, noncompliance, difficulty contacting participants, health behavior issues, questions about referrals to other providers, etc.

◦ These keep our staff informed about any issues that might be impacting services or progress in a participant’s program.

Follow Ups

Please be sure that documentation is done in a timely manner.

Documentation should be done during the month of your visit so that facilities can be reimbursed.

There is a 6 month timely filing policy. If your documentation is not complete in 6 months, the service will not be reimbursed.

Any questions about documentation, please contact;

◦ Cathy Shaw RD, LDRD Program Coordinator304-293-6652catherine.shaw@mail.wvu.edu

Documentation Deadlines

History Tester is a 63yo F with PMH of hyperlipidemia, depression and anxiety. Has been on antihyperlipidemic meds for about 7 years. Currently takes Crestor. Takes Paxil for

dep/anx. Labs: HDL 53; LDL 106; Trig 147; Tchol 188; Glu 57. Ht: 5'6"; wt: 204lb; BMI: 32.4; WC: 43.7"; BF 42.5%. Has been at current weight range for about 10 years. Started gaining weight after her 2nd child was born (1983). At one point she got sick and lost down to 160lb, but regained weight when illness resolved. Currently at her highest weight. Has tried to lose weight in the past several times. Used Weight Watchers, but could never meet her goal and got burned out. Never got into using a food diary. Liked Weight Watchers because she did not feel she was starving herself. Has decided that our program can help her improve her health. Her husband passed away several years ago and she does not want to be a burden on her children in the future; wants to be healthy and independent. She is tired of being overwt and feels like this is her last chance.

Assessment Current BMI indicates grade I obesity; WC increases health risk. She has lost 3lb since her initial weigh in (207lb). Her labs were unremarkable- remains on meds for lipid

management. States Paxil is effective for mood/anxiety. Diet hx is variable. She does not cook much because she lives by herself and her children are not really close by. She will eat out about 3x/wk and does pick up convenience foods at the grocery store frequently (pre-prepared chicken or deli sandwich, etc.) She does often have a frozen meal for dinner such as Healthy Choice or Lean Cuisine. Has made a recent attempt to purchase more healthy foods for home- oats, yogurt, celery, etc. She likes to snack a lot on things like chips and she has dessert 2-3x/wk. She does not really plan her meals ahead of time. Knows she needs to start making healthy choices at restaurants and watching portion sizes. She feels she needs some ideas for substitutions for the "bad" choices she is making. Current needs are between 1400 and 1500 calories per day for gradual weight loss of 1lb/wk. She is working out 3x/wk at the fitness center and she does plan on doing a lot of outside work this summer. Likes to garden and do outside chores. Nutrition knowledge base is fair. She feels that she is ready to make some changes to her eating habits. Rated her confidence in making changes at >5/10. Willing to take the time to meal plan and shop, especially since school will be out soon (she is a teacher). Possible barrier could be vacation in Las Vegas, but she already has actins steps planned to keep her on track (going with a relative with similar goals, portion control, physical activity).

Nutrition Diagnosis Nutrition Dx: Obesity r/t excessive energy intake from high calorie snack foods, desserts, convenience foods and eating out without modifying food selection AEB BMI of

32.4. Will follow progress via facility measurements, on line contact, food intake records and client report. Follow up has been scheduled. CLS

Education/Interventions Nutrition prescription: 1400-1500 Kcal heart healthy eating plan based on the principles of My Plate. We discussed meal planning strategies to help limit need to stop at

the store for convenience items. Went over how to plan meals around frozen meal replacements as well. She was interested in healthy snack ideas and we were able to find some acceptable substitutes for things she currently chooses. Discussed appropriate choices and strategies for eating healthy when eating out with friends. Encouraged her to read food labels beginning with serving sizes, calories and fat content. She feels she eats dessert too often and we made a plan to cut back, but not eliminate so she does not feel deprived. She was willing to try keeping a food intake journal, so she has printed out a manual journal worksheet to start keeping track. She verbalized good understanding of info discussed and was able to formulate some goals she feels comfortable with. Motivated to take action steps. she has been given a sample meal planner and basic nutrition ed materials for her educational reference.

Goals/Monitoring Goals: Tester will start taking 15-20 min on Sundays to plan meals and snacks for the week before she does her grocery shopping. She plans to decrease dessert intake to

1x/wk. She plans on substituting popcorn or other appropriate sub we discussed (baked tostitos or baked chips, almonds, vegetables, fruit)for potato chips as a snack. She will also try keeping a food log daily.

Documentation Example

Met with Tester for her 6-month follow up RD visit. Paula indicates no changes in current medical hx or medication. She has continued to track her diet intake using Weight Watchers online but admits to being less consistent with recording all food intake for the past month or so. A family death, oversight of a state conference and load at work have all contributed to Paula getting off of routine somewhat.

Assessment Current weight of 194.5 indicates a gain of 5.8 lbs. since our last session on 3-27-13 and an overall loss of 5 lbs since her start date of 10/31/2013. Current

BMI of 35.5 remains Class I Obesity. Waist circumference is 38, just 0.5 inches less than that recorded at start date. Disease risk remains very high due to BMI and waist measurement combination. She shared no food intake records today but assures that she will be tracking with Weight Watchers again.

Nutrition Diagnosis Nutrition Dx remains Obesity Level I r/t weight regain of 53.7% of total weight lost since start date AEB BMI of 35.5 and waist circumference of 38 inches.

Will follow up via telephone and email prior to month 9.

Education/Interventions Today, Tester and I discussed barriers to weight maintenance when day to day routines are broken. Tester has been consistent with her exercise routine at

Fairmont Fitness, but has not been as successful at adding additional activity in the past 2 months. We also discussed her upcoming trip to Italy and the importance of taking advantage of activities and walking to increase energy output and how to enjoy the food oppportunities while controlling poritons, enjoying a slower more relaxed pace and the company of friend while dining, and avoiding the pitfalls of too many high calorie treats. Client indicated that she does not intend to track intake while traveling but will be conscious of food choices to avoid weight gain. We reviewed additional tips for making wise food choices while traveling.

Goals/Monitoring Nutrition Prescription remains 1400-1500 kcalorie carbohydrate controlled low-fat healthy eating plan. Client will begin consistently logging food intake

after her return from Italy but will be cautious of portion sizes and food choices while traveling. Goal for next 2-3 weeks is weight maintenance with balance of activity, wise food choices, and portion control. Goals beginning in July will be consistent tracking of food intake, maintenance of workout routine at Fairmont Fitness, addition of at least 10 minutes of activity during a morning break and additional outdoor activity on evenings and weekends, and packing lunch 2-3 days/week rather than dining out.

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Another example: