Fluid Intake: Assessing Fluid Needs & Documenting Intake

1.1 Nutritional screenings, including dehydration risk factors, are obtained from clients and from medical record review in a timely manner that complies with regulatory agency guidelines.

Hydration forms and checklists:
✓ Providers Web (for a fee)
✓ AND Nutrition Care Manual
✓ RD411.com

1.2 Client fluid needs are assessed based on an individualized basis and considering clinical status.

Estimating Daily Fluid Needs

For Average Adults: 30 mL/kg

For Adults with Infection or Draining Wounds: 35 mL/kg

For Adults with CHF or Renal Disease: 25 mL/kg

Note: 1 oz = 30 mL or cc

1.3 Hydration interventions are added to the plan of care and documented in the clients’ medical record.

2.1 The menu includes a predetermined amount of fluid to be provided for clients each day.

✓ Foodservice staff has a notification system for clients on fluid restriction or have additional fluid needs.

2.2 Daily fluid intake is recorded for new clients and those at risk for dehydration.

✓ Include all fluid intake including during and between meals.

2.3 Fluid intake is entered into the medical record by qualified staff according to state regulations.

2.4 Facility has a hydration intervention policy and procedure in place for clients who are at risk for dehydration.

✓ Policy includes role of interdisciplinary team (RDN, RN, Speech or Occupational Therapy and others)

2.5 For clients at risk of dehydration: assessment of hydration/dehydration is evaluated, interpreted, and documented in the client's medical record by the Registered Dietitian Nutritionist (RDN)

2.6 Qualified foodservice staff is trained on documenting fluid intake on standardized forms approved by the facility.

Competence Training:
✓ CDM, CFPP trains staff on documenting fluid intake & other functions applicable to their job
✓ CDM, CFPP documents competence training/in-service attendance and competence skill testing evaluation
✓ CDM, CFPP keeps records in the department