Administrative Departmental Policy
This department-specific policy applies to the operations and staff of the Clinical Nutrition Services
Department of the University of Wisconsin Hospitals and Clinics Authority as integrated effective July 1,
Policy Title: Nutritional Care and Monitoring for Inpatients at University Hospital and The
Policy Number: 3.3
Effective Date: November 20, 2002
Revision Date: January 12, 2017
To establish guidelines for the nutritional care and monitoring of hospitalized patients
with different levels of nutritional risk.
II. POLICY ELEMENTS
Nutrition care is a component of patient screening, assessment, and reassessment during
hospitalization. Following nutrition screening, nutrition assessments are performed by a
Registered Dietitian Nutritionist (RDN) who is registered with the Commission on
Dietetic Registration of the Academy of Nutrition and Dietetics (AND), certified in the
state of Wisconsin, and employed at UW Health. Clinical Nutrition Service staff
provides nutrition care to patients and functions as members of the interdisciplinary
health care team. Nutrition Technicians and Dietetic Interns deliver nutrition care under
the direction of the RDN. Resources available to the RDN for medical nutrition therapy
and nutrition care planning include established policies and procedures, the AND
Nutrition Care Manual, Clinical Practice Guidelines, and Delegation/Practice Protocols.
All patients receive nutrition care based on the specific needs of the individual
patient. Nutrition care includes the following: 1) nutrition screen, 2) nutrition
assessment, 3) development of a nutrition plan of care, 4) monitor the patient relative to
the nutrition care process, 5) reassess needs as appropriate, and 6) educate the patient on
diet and nutrition as appropriate.
A. Patients at nutritional risk as identified by the admission health assessment and/or
discipline nutrition screen are further assessed by the clinical nutritionist or designee
within 72 hours of admission and will be assigned an acuity level (low, moderate, or
high). Patients that are identified to be at nutritional risk based on the admission screen
score of 2 or greater will be assessed within 72 hours regardless of acuity level unless the
screen was a false-positive. Nutrition consult or referral by a physician or a health care
practitioner initiates RDN documentation in the medical record which may include a
nutrition assessment. In addition, patients with a poor appetite and inadequate nutrient
intake of several days, altered absorption due to disease or surgery, increased nutrient
needs, or a change in medical condition or therapy are assessed.
B. The Nutrition Care Process is a systematic approach that provides a framework for the
RDN to individualize care, taking into account the patient's needs and values and using
the best evidence available to make decisions.
The Nutrition Care Process consists of the following steps:
1. Nutrition Assessment: The RDN collects and documents information such as
food or nutrition-related history; biochemical data, medical tests and procedures;
anthropometric measurements, nutrition-focused physical findings and client
2. Diagnosis: Data collected during the nutrition assessment guides the RDN in
selection of the appropriate nutrition diagnosis (i.e., naming the specific problem).
3. Intervention: The RDN then selects the nutrition intervention that will be
directed to the root cause (or etiology) of the nutrition problem and aimed at
alleviating the signs and symptoms of the diagnosis.
4. Monitoring/Evaluation: The final step of the process is monitoring and
evaluation, which the RDN uses to determine if the patient/client has achieved, or
is making progress toward, the planned goals.
C. A summary of the nutrition assessment and plan of care will be documented in the
patient's medical record.
D. Nutrition Acuity is assigned following screening as either low, moderate, or high. Acuity
is determined by disruption in intake, increased losses, increased needs, malabsorption,
issues related to malnutrition, weight, age, and organ failure. Patients with a low acuity
will be assessed or re-screened within 7-10 days as no or low nutritional risk, moderate
acuity will be assessed within 5 days, and high acuity will be assessed within 3 days (72
hours) of admission.
E. The patient's status is continually monitored during patient care rounds and conferences,
if their level of care changes requiring unit transfers, and with chart review for other
pertinent information; acuity may be changed based upon these conditions. A patient that
is NPO for 5 or more consecutive days will be assessed.
F. Nutritional care for at risk patient is reassessed within 7-10 days but may be adjusted on
an individual basis when there is a change in the patient's medical condition that requires
modification, when patient transfers to a higher or lower level of care, and when nutrition
problems have resolved. Patients acutely hospitalized, screened and re-screened at no or
low nutrition risk, will be assessed within 14 days length of stay. If no nutrition diagnosis
is identified at the time of the assessment, the patient may be re-screened low the
following week resulting in a re-assessment every 14 days only if the patient remains at
no to low risk.
G. Patients who are receiving comfort care will be evaluated and monitored every two
weeks unless otherwise indicated. No full assessment is required, but the RDN or
designee will document comfort care and honor any diet orders/patient preferences as
H. Patients who are receiving hospice care will be screened upon admission. The RDN will
visit the patient and/or family and explain the nutrition services available, which include
assessment, education, and intervention. To provide patient and family centered care, the
patient and/or family will be given the choice to decline nutrition services regardless of
malnutrition risk level determined during the screening process. Nutrition will be
available by consult.
I. For continuity of care of patients who require additional nutrition intervention after
discharge, the RDN will recommend referral to the appropriate support service.
ξ UW Health Policy No. 8.47, Screening, Assessment and Reassessment of Patients:
ξ Joint Commission Standards for the Hospital, Lab and Home Care Surveys:
ξ Centers for Medicare and Medicaid Services (CMS) Conditions of Participation:
ξ Academy of Nutrition and Dietetics. Nutrition Care Manual:
ξ Academy of Nutrition and Dietetics. eNCPT, Nutrition Terminology Reference Manual,
Dietetics Based Language for Nutrition Care:
ξ UW Health Clinical Practice Guidelines: https://uconnect.wisc.edu/clinical/cckm-
ξ UW Health Delegation/Practice Protocols: https://uconnect.wisc.edu/clinical/cckm-
Sr. Management Sponsor: Chief Nursing Officer and Senior Vice President Patient Care Services
Author: Director Clinical Nutrition Services
Review/Approval Committee(s): UW Health Medical Board Nutrition Committee
Megan Waltz, MS, RD
Director, Clinical Nutrition
Sue Rees, DNP, RN, CPHQ, CENP
VP Development, Nursing & Patient Care Services
Previous revision: September 4, 2015
Next revision: January 12, 2019