WIC Nutrition Education Documentation

On this page: 
Documentation Should Enhance Continuity of Care | Documentation Options | Documentation Best Practices - Suggested Activity | Using the Information System's Nutrition Education Page | Information System Notes | Documenting High Risk Individual Nutrition Care Plans | SOAP Documentation | Sample High Risk Individual Nutrition Care Plans using SOAP Documentation |

Documentation assures that education was provided as required. But more importantly, the purpose of nutrition education documentation is to facilitate the delivery of meaningful nutrition services and to ensure continuity of care for participants. It is the primary means by which WIC staff communicate with each other about individual participants. Documentation should:

• Capture a picture of the participant’s visit in a way that is easy to retrieve and review.
• Facilitate CPA follow-up so previous education can be reinforced.

Documentation Should Enhance Continuity of Care

Local agency documentation procedures should facilitate continuity of care. That means documentation procedures should:

• Be followed consistently by all staff in the agency to minimize duplication of information. Plus, if documentation is done consistently, staff don’t waste time searching for information!
• Be clear so that other staff can easily understand what the author is communicating. Use established terminology and abbreviations.
• Describe the services provided to help other staff understand the plan for future services.
• Be concise so that it contains pertinent information and minimal extraneous information. For example, including that a healthy 8-month infant “started crawling” or “likes to play peekaboo” is extraneous information since it covers typical milestones for a child of that age. Such information doesn’t contribute to the nutritional care of the infant. Instead, document only those things that are significant and relevant to follow-up. A parent of an 8-month-old may have developmental concerns if the child is not attempting to crawl yet or doesn’t interact with others. Documenting this information can contribute to the care of the participant.

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Documentation Options

Local agencies have options on where to document nutrition education. The following options are available in the Minnesota WIC Information System:

• Nutrition Education page in the Information System – Use the nutrition education page to document general topics discussed, materials given, peer referrals, and goals. The page works well for documenting low-risk topics.
• Notes – use the “notes” functionality for narrative documentation. Notes can be used for nutrition education documentation for both low risk and high-risk participants.

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Documentation Best Practices - Suggested Activity

At a staff meeting, review your documentation procedures and ask the following questions:

• Are all staff consistently following the same procedures for documenting?
• When you open a participant folder, are you able to quickly find the nutrition education documentation from the previous visit?
• When you review documentation from a participant’s previous visit, can you quickly determine the plan for follow-up? How can staff more clearly communicate the follow-up plan?
• What extraneous information do you see documented in participant folders? Talk about opportunities for documenting more concisely.

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Using the Information System's Nutrition Education Page

As we talk about best practices for Nutrition Education Documentation, it is important to remember that Nutrition Assessment and Nutrition Education are two separate functions.

• Assessment is the process of obtaining and synthesizing information about a participant’s nutrition status to provide the most appropriate individualized WIC services.
• Nutrition Education is an interaction between a CPA and participant designed to inspire positive change in diet and/or physical activity to improve health.

Nutrition Assessment Page vs. Nutrition Education Page in the Information System

• The two pages allow staff to document the assessment and education functions separately. The results of your assessment are documented in the Nutrition Assessment page (or in notes if that is your agency’s procedure) and include the assignment and justification for risk codes. Education provided is documented in the Nutrition Education page (or in notes if that is your agency’s procedure) and includes those topics/areas for which education was provided. Both assessment and education can be documented in notes but should be distinct.
• Documentation of your assessment is critical for directing education and determining follow-up. But CPAs are not required to provide education on every identified risk. Therefore, a nutrition/health concern may be documented in the Nutrition Assessment page (or in notes) for which education is not provided. That is why is important to keep documentation of assessment distinct from documentation of education.

Nutrition Education Page is like a Checklist

• Use the page to quickly document nutrition education topics, materials, peer referrals, and goals. The page provides a simple system for documenting required topics such as “the risks of using drugs and other harmful substances” or items covered to orient new families to the program.
• Use the page to document low-risk nutrition education contacts.

Best Practices - Using the Nutrition Education Page

• Document only items that were discussed. Don’t document items that were assessed but about which education was not provided. For example, if you do a blood draw and determine the value is normal, there is no need to document that in the participant’s Nutrition Education page. Likewise, if you ask about a child’s milk intake and determine it is probably appropriate, do not select that topic in the Nutrition Education page.
• Limit the number of items “checked”. A long list of topics, materials and/or goals is not helpful and detracts from our goal of documenting for Continuity of Care. The next CPA to see that participant will not be able to discern the primary topics of discussion from a long list.
• The lists in the Nutrition Education Page are statewide, not agency-specific, so they are general in nature. This means CPAs cannot individualize the topics or goals to the participant. If you would like to include more specificity about a nutrition education topic or about a goal that was set, use notes.

Suggested Activity

If your agency uses the Nutrition Education page for nutrition education documentation, review your documentation procedures and ask the following questions:

• Do staff use the Nutrition Assessment page for documenting assessment and Nutrition Education page for documenting education? If your agency uses notes for documenting both functions, can you distinguish between the assessment documentation and the education documentation?
• Are “just the topics discussed” documented in the Nutrition Education page or are multiple items frequently checked? When you open the Nutrition Education page in a participant’s folder, are you able to quickly discern the education provided at the last visit?
• How might your agency enhance the use of the Nutrition Education page, so it is more effective and facilitates continuity of care? Is there enough information to make the next contact with the participant meaningful and substantive?

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Information System Notes

Use notes for narrative documentation:

• When you would like to document any information or education individualized to the participant. Topics in the Nutrition Education page are broad and general in nature. Notes allow you to document education specific to the participant.
• When you document high risk care plans and follow-up.

Types of Notes

• General notes have various subjects to select from, based on the topic of your note.
• SOAP note template auto-populates information from the most recent certification. Please note: There are other acceptable documentation methods besides SOAP. An agency may use another documentation process, such as PES, as outlined in their agency’s Nutrition Education Plan.
• Breastfeeding notes are also available.

Best Practices - Notes

Think about the desired outcome of documentation. Documentation should capture a picture of the participant’s visit in a manner that is easy to review, build upon and follow-up on at future visits. To capture the “picture”, include the following in a note:

• Assessment:
  • Briefly note the key participant concerns, interests and/or strengths.
  • Be concise and avoid extraneous information that doesn’t contribute to the nutrition care of the participant. Provide relevant information succinctly. One simple tip: don’t spend time documenting typical developmental milestones for a healthy child. Documenting that a healthy 9-month child is “starting to pull himself up along furniture, attempting first steps” doesn’t add meaningful information for nutrition follow-up. Instead, document concerns that are outside of expected parameters.
• Nutrition Education Provided:
  • Ideally, the education should be geared to the interests of the participant and/or identified nutrition concerns.
  • Meaningful documentation is specific! Documenting “recommended more high iron foods” for a child with a low hemoglobin doesn’t provide specificity needed for follow-up. The education should relate back to the assessment. What dietary or medical factor might be contributing to the low hemoglobin? An example: Two-year old child has a hemoglobin of 10.4 at certification. Mom reports the child doesn’t eat any meat and snacks on chips. As you discuss options with the mother, she decides to “try mixing ground beef into casseroles and to offer WIC cereal for snacks”. Documenting these specific activities provides meaningful information for continuity of care.
• Plan for follow-up
  • Indicate a timeline for follow-up.
  • Identify specific issues or goals to review at follow-up.

Suggested Activity

At a staff meeting, review your documentation procedures for notes and ask the following questions:

Are notes concise? Is there extraneous assessment information in notes that doesn’t contribute to the nutrition care of the participant? Talk as a staff about documentation practices that promote succinct documentation. Here is an example of a healthy three-year-old child with no high-risk conditions:

• The note reads: “She is a good eater. Favorite foods are salad with ranch dressing, tacos, blueberries, cauliflower, broccoli, chicken, toast, and olives”.
• Let’s make the nutrition education documentation more specific! “Mom will offer milk at every meal. Added yogurt to food package to try.”

Is documentation of Nutrition Education specific to the participant rather than general or ambiguous? Does the education and documentation relate to the assessment? Does it provide meaningful information for future follow up? Here are some examples.

• Example 1: Per your assessment, mom is concerned child is not getting enough milk. The child is drinking milk only at supper. Rarely eating other milk products.
  • The nutrition education documentation reads: “More milk.”
  • Let’s make the nutrition education documentation more specific! “Mom will offer milk at every meal. Added yogurt to food package to try.”
• Example 2: Per your assessment, pregnant woman is only eating 2 times a day due to busy work and school schedule.
  • The nutrition education documentation reads: “Eat more frequently.”
  • Let’s make the nutrition education documentation more specific! “Will take some quick snacks along to work/school to eat on breaks. Will try cheese, fruits, yogurt, and peanut butter sandwiches.”

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Documenting High Risk Individual Nutrition Care Plans

A High-Risk Individual Nutrition Care Plan (INCP) is developed for each participant who meets the Minnesota WIC Program High Risk and Medical Referral Criteria. Section 6.6: High Risk Individual Nutrition Care Plans states that an INCP must be developed and documented specifically addressing high risk condition(s) identified and must include:

• Assessment of individual’s overall situation including nutrition status, needs, and any problems.
• Review of health services for the high-risk condition being provided elsewhere.
• Specific goals/recommendations regarding the high-risk condition.
• Referrals to healthcare providers and other programs and services as needed.
• Plans for follow-up visits.

Putting the High-Risk Policy into Action!

• The plan should specifically address the high-risk condition(s). Focus the documentation of your assessment, goals/recommendations, and follow-up plans around the high-risk condition(s).
• As you complete a WIC Nutrition Assessment using the ABCDE tool, think critically about what factors might be contributing to the high-risk condition. Here are some examples:
  • Scenario #1 - A pregnant woman in her 1st trimester has lost 7 pounds and is assigned risk factor 131 - Low Maternal Weight Gain and meets the High Risk Criteria. Assess and document those factors that may be contributing to the weight loss. Is the woman experiencing nausea and/or vomiting? Is she eating less or skipping meals? Does she have adequate access to food? Document your assessment, focusing on what may be contributing to the weight loss. In this scenario, the woman indicates “she is too nauseous to eat. Just eating a couple times a day”.
  • Scenario #2 - A 3-year-old child is above the 95% BMI and has gained 10 pounds in the last 6 months. Risk Factor 113 - Obese is assigned and he meets the High Risk Criteria. Assess and document those factors that may be contributing to the rapid weight gain. What is the child’s meal and snack pattern? What types of beverages is the child drinking? What is the child’s activity pattern? Have there been any major changes in the child’s life that may be affecting his weight? Document your assessment, focusing on what may be contributing to the rapid weight gain. In this scenario, the parents share that “both parents are working and rely on elderly grandmother to watch the child. She has limited mobility, so the child spends most of the day watching TV. He snacks a lot, but parents are not sure what he is eating for snacks.”
• Using your PCS skills and techniques, determine specific goals/recommendations with the participant/caregiver for addressing the high-risk condition. Here is some specific documentation for our high-risk participants:
  • Scenario #1 - In discussion with the pregnant woman, she sets a goal to “Eat small amounts, 6-8 times/day. Try crackers, toast, and dry cereal when nauseated.” Document these specific goals/recommendations.
  • Scenario #2 – After discussing the child’s current activity level and snacking habits, the parents decide to “have some active family time after work and on weekends. Discussed some options such as take a walk, go to the park, check out Community Education programs for open gym and pool times. Will send a healthy snack (fruit, yogurt, cereal, graham crackers) for the son to the grandmother’s house every day.” Document these specific goals/recommendations.
• Review the health care that the participant is receiving elsewhere. Are they receiving appropriate services to help alleviate the high-risk condition? Do they need any referrals to other services?
  • Scenario #1 - The pregnant woman is receiving regular prenatal care and the physician is aware of her nausea and weight loss. She doesn’t require a health care referral. However, she does express concern about having enough food for her family when her SNAP runs out. “Gave information for the Community Food Shelf and she plans to go this week.”
  • Scenario #2 - The 3-year-old child is due for a well-child checkup. “Parents will schedule a well-child checkup. Referral sent to physician regarding child’s weight status.”
• Plan for follow-up visit. Document timeline for follow-up and include key areas for follow-up.
  • Scenario #1 – “Follow-up scheduled for December. Check weight. Ask about nausea, frequency of eating. Did she receive assistance from food shelf?
  • Scenario #2 – “Follow-up scheduled for February. Follow up on the well-child checkup and the referral to physician. Ask about physical activity and snacking.”

Suggested Activity

At a staff meeting, review your documentation procedures for High Risk INCPs and ask the following questions:

• Do High Risk INCPs focus on the high-risk condition(s)? Does each INCP identify factors that may be contributing to the high-risk condition(s)?
• Are goals/recommendations specific and tailored to the individual and their identified needs/concerns?
• Is the plan for follow-up clear, i.e., another CPA can quickly determine the plan and provide appropriate follow-up?
• On the next page, review the SOAP documentation method. Since the Information System has a SOAP template, SOAP is the focus of this memo. Your agency may use another documentation method as outlined in your Nutrition Education Plan. Most importantly, the method needs to meet all the requirements for INCP documentation.
• On the last page, see the INCPs written for the two scenarios in this memo. Since the Information System has a SOAP template, these INCPs were written using the SOAP method.
  • Discuss how the assessment and education information is documented in these two examples. What might you do differently?
  • Discuss if there is adequate information in each note to provide continuity of care. Could you open one of these records and provide follow-up?

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SOAP Documentation

S stands for Subjective and may include:

• Information collected from talking with an individual.
• An individual’s thoughts or feelings.
• An individual’s description of his or her problems.
• Dietary intake or reported food habits.

O stands for Objective and includes:

• Facts you collect, tangible findings, and your clinical observations.
• Physical findings.
• Factual information regarding background or history.
• The Information System auto populates some participant data into the template for “O”, including anthropometric data, bloodwork, and risk factors. The CPA may add other objective data as needed.

A stands for Assessment and includes:

• Your assessment or impression of the individual’s overall situation.
• Summary and evaluation of diet and nutritional status.
• Meaning of the information collected.
• Problem definition or interpretation.

P stands for Plan and includes:

• Specific goals and recommendations regarding the high-risk condition(s).
• Any additional information that is needed and plan for obtaining that information.
• Referrals that were made.
• Recommendations, plans, and timeline for follow-up visits.
• Educational materials used and/or given to the individual.

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Sample High Risk Individual Nutrition Care Plans using SOAP Documentation

Scenario #1: Pregnant woman in 1st Trimester with Maternal Weight Loss

S: Has nausea all day long, vomits occasionally. She reports she is too nauseous to eat. Just eating a couple times a day. Mostly drinking water, doesn’t like milk. Drinks milk 1 time/day. Struggles with feeding family when they run out of SNAP. Plans to breastfeed.

O:
11/20/2023 64 5/8 inches, 123 pounds 4 ounces
11/20/2023 HGB: 12.4

Risk Factors Assigned on 11/20/2023
131 Low Maternal Weight Gain 
401 Failure to meet Dietary Guidelines for Americans

A: Weight loss of 7 pounds, may be due to nausea/infrequent eating and inadequate food resources.

P: Goal is to eat small amounts, 6-8 times a day.

• Avoid empty stomach. Try crackers, toast, and dry cereal when nauseous.
• Gave information for the Community Food Shelf and she plans to go this week.
• Follow-up scheduled for December. Check weight. Ask about nausea, frequency of eating. Did she receive assistance from food shelf? If time, ask about milk intake.

Scenario #2: Three-year-old child >95% BMI, showing rapid weight gain on growth chart

S: Parents surprised by rapid weight gain. Both parents working and rely on elderly grandmother to watch child. She has limited mobility so the child spends most of day watching TV. He snacks a lot, but parents are not sure what he is receiving for snacks. Due for well-child checkup.

O: 
11/20/2023 41 7/8 inches, 46 pounds 4 ounces
Height for age percentile: 97.33%
Weight for age percentile: 99.37%
11/20/2023 HGB: 12.5

Risk Factors Assigned on 11/20/2023
113 Obese (Children 2-5 Years of Age) 
401 Failure to meet Dietary Guidelines for Americans.

A: BMI 97.48%. Rapid weight gain may be due to high screen time, low activity, excessive snacking.

P: Goal is to have some active family time after work and on weekends.

• Discussed some options such as take a walk, go to the park, check out Community Education programs for open gym and pool times.
• Will send a healthy snack (fruit, yogurt, cereal, graham crackers) for the son to the grandmother’s house every day.
• Parents will schedule well-child checkup.
• Referral sent to physician regarding child’s weight status.
• Follow-up scheduled for February. Follow up on the well-child checkup and the referral to physician. Ask about physical activity and snacking.

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