Activity 5

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Q1. Screening at Admission * This field is required.On your first day of this project, you notice malnutrition risk screenings are often delayed until several days after admission, and sometimes never completed.
Advocate for completing malnutrition risk screenings within 24 hours of admission, following facility, CMS, and Joint Commission standards.
Assume delays are fine because the nurses are too busy and focus only on patients who are already referred.
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Correct!
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Incorrect.
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Q2: Team Buy-In * This field is required.During a staff huddle, several nurses mention that malnutrition screening feels like "extra work" and not a priority compared with other tasks. This attitude may lead to inconsistent screening compliance.
Provide evidence linking malnutrition screening to patient outcomes. Review with nursing how screenings can be incorporated into current workflows. Advocate for training and establishing procedures.
Ignore their concerns andcontinue to expect compliance without explanation
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Correct!
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Incorrect.
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Q3: Documentation Dilemma * This field is required.As you review the EHR, you see RDN chart notes such as “protein-calorie malnutrition” and “wasting disease,” as well as some that use standardized NCP terms. This inconsistency confuses providers and makes MCS scoring harder (MO2: Nutrition Assessment).
Recommend everyone use structured drop-down menus and standardized NCP terminology to ensure documentation aligns with AAIM criteria, NCP terminology, and supports MCS data capture.
Keep writing free-text notes because each dietitian has their own style.
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Correct!
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Incorrect.
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Q4: The Provider Puzzle * This field is required.Later that week, you discover that physicians sometimes diagnose malnutrition on their own without reviewing the RDN’s PES statements. This creates discrepancies between clinical providers (MO3: Provider Malnutrition Diagnosis).
Suggest to CNM to discuss with leadership the option of adding an automatic EHR alert so providers can review and confirm the RDN’s findings before finalizing malnutrition diagnoses.
Do nothing. Providers are experts in their field, and their notes will carry the most weight.
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Correct!
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Incorrect.
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Q5: Care Plan Conundrum* This field is required.When reviewing additional data collected, you notice that the score for MO2 Nutrition Assessment is higher than the score for the MO4 Nutrition Care Plan. You know, RDNs typically document using ADIME, and if there is a nutrition diagnosis, there is usually a care plan. What could be the reasons behind this discrepancy? (select all that apply)
The RDN is using free text to document the care plan
The template is not correctly linked to the appropriate terminology
There is no intervention (care plan) section developed in the template
There is no terminology mapped to the free text box
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Correct!

The RDN is using free text to document the care plan

The template is not correctly linked to the appropriate terminology

There is no intervention (care plan) section developed in the template
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Incorrect.

Correct Responses:

The RDN is using free text to document the care plan

The template is not correctly linked to the appropriate terminology

There is no intervention (care plan) section developed in the template
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Q6: The Path Forward * This field is required.At this point, you have worked with your CNM to discuss your department’s needs with leadership, nursing, and medical staff. With the goal of implementing the MCS measure in your facility, what are the possible high priority actions you should take? (select all that apply)
Focus efforts only on patients already referred to the nutrition team
Work with nursing to support processes to improve malnutrition screening compliance
Advocate with leadership to support the process improvement steps to complete MCS implementation
Collaborate with RDNs to develop standardized EHR templates and drop-down menus for documentation
Work with IT staff to implement templates developed and map key terminology to the correct codes (SNOMED, ICD-10, etc.)
Advocate for NFPE training workshops and refresher sessions for RDNs
Respect each RDN’s work process and continue using free-text documentation
Ignore staff concerns about workload and expect compliance without explanation
Engage medical provider leadership to add EHR alerts for provider-RDN diagnosis alignment
Develop a triage system for high-risk patients to prioritize malnutrition care
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Correct!

Work with nursing to support processes to improve malnutrition screening compliance

Advocate with leadership to support the process improvement steps to complete MCS implementation

Collaborate with RDNs to develop standardized EHR templates and drop-down menus for documentation

Work with IT staff to implement templates developed and map key terminology to the correct codes (SNOMED, ICD-10, etc.)

Advocate for NFPE training workshops and refresher sessions for RDNs

Engage medical provider leadership to add EHR alerts for provider-RDN diagnosis alignment

Develop a triage system for high-risk patients to prioritize malnutrition care
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Incorrect.

Correct Responses:

Work with nursing to support processes to improve malnutrition screening compliance

Advocate with leadership to support the process improvement steps to complete MCS implementation

Collaborate with RDNs to develop standardized EHR templates and drop-down menus for documentation

Work with IT staff to implement templates developed and map key terminology to the correct codes (SNOMED, ICD-10, etc.)

Advocate for NFPE training workshops and refresher sessions for RDNs

Engage medical provider leadership to add EHR alerts for provider-RDN diagnosis alignment

Develop a triage system for high-risk patients to prioritize malnutrition care
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Q7: Quality Improvement Query* This field is required.You have completed some process improvement steps, and your CNM now asks you to present your findings and improvements to leadership. To gather that information, you need to select the correct data to track and report on to show your team’s progress.
Pull data from EHR on completion of: Nutrition risk screening completed, Nutrition assessment completed, Nutrition care plan when a malnutrition diagnosis is present, Malnutrition medical diagnosis documented
Only track the number ofpatients that were seen by the RDNs.
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Correct!
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Incorrect.
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Q8: Barriers all around* This field is required.During a team meeting, your CNM asks you to present your findings; however, you notice the tension in the room. When presenting, you ask the team about what's holding them back. They share that limited EHR training, inconsistent NFPE skills, and heavy workloads make it hard to complete all the steps in their workflow.
Propose an action plan to your CNM that includes NFPE training workshops, IT support for standardized templates, and a triage system for high-risk patients.
Address the team by saying: their work is not complicated, and that they should try harder.
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Correct!
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Incorrect.
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Q9: Making Progress* This field is required.After piloting your changes for a month, you crunch the numbers: ● Screening compliance ↑ by 20% ● Consistency in documentation ↑ by 30% ● Provider-RDN agreement ↑ by 30% ● MCS score improved from 65% → 82% Now leadership asks what you’ll do next.
Present results, refine based on feedback, and propose changes facility-wide.
No need to share resultswith the team.
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Correct!
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Incorrect.
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Q10: All Coming Together* This field is required. After implementing new NFPE training and EHR templates, you see improved compliance for a few weeks. However, by the third month, documentation rates begin declining again.
Propose ongoing audits and quick refresher training to reinforce expectations and sustain progress.
Assume the initial improvements prove theproblem is solved and move on to another project.
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Correct!
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Incorrect.
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Q11: Completing Process Improvement * This field is required.Leadership asks you to present your project outcomes to the hospital’s Quality Committee. You know they’ll want to see both clinical and financial impacts.
Highlight improvements in MCS scores, patient outcomes, and potential cost savings (e.g., reduced length of stay/readmissions), linking them to quality priorities.
Only showraw numbers of completed screenings and assessments, without connecting them tobroader impacts.
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Correct!
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Incorrect.
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