1.2 Nutrition Screening & Care Process
Key Takeaways
- Nutrition screening is a quick process to flag at-risk residents; nutrition assessment is the in-depth follow-up evaluation
- The CDM typically performs screening and gathers data; the Registered Dietitian Nutritionist (RDN) performs the full assessment and diagnosis
- The four steps of the Nutrition Care Process are assessment, diagnosis, intervention, and monitoring/evaluation
- Risk indicators include unintended weight loss, poor intake, pressure injuries, dysphagia, and abnormal labs
- Accurate, objective, timely documentation in the medical record supports the care plan and survey compliance
Knowing exactly who does what in nutrition care is one of the most frequently tested concepts on the CDM exam. The board wants to confirm you can act within your scope — screening and supporting — without crossing into the dietitian's clinical territory.
Screening vs. Assessment
These two terms are constantly confused, so anchor the distinction now.
| Nutrition Screening | Nutrition Assessment | |
|---|---|---|
| Purpose | Quickly flag who is at risk | Diagnose and plan in depth |
| Speed/depth | Brief, surface-level | Comprehensive, detailed |
| Typical performer | CDM (or trained staff) | RDN (dietitian) |
| Output | Referral to the RDN | Nutrition diagnosis and plan |
Think of screening as the smoke detector and assessment as the fire investigation. The CDM screens every resident on admission and on a schedule, then refers anyone flagged to the dietitian.
CDM Role vs. RDN Role
- The CDM screens residents, gathers food preferences and intake data, monitors meal acceptance and weights, implements diet orders, and documents observations.
- The Registered Dietitian Nutritionist (RDN) performs the comprehensive assessment, establishes the nutrition diagnosis, and designs the medical nutrition therapy plan.
The CDM works under and alongside the RDN — collecting data and carrying out the plan, but not making the clinical diagnosis.
The Nutrition Care Process (NCP)
The Academy of Nutrition and Dietetics standardized care into four steps:
- Nutrition Assessment — collect and analyze data
- Nutrition Diagnosis — identify the specific nutrition problem
- Nutrition Intervention — act (diet change, supplement, education)
- Nutrition Monitoring and Evaluation — measure outcomes and adjust
Identifying At-Risk Residents
Flags that should trigger a referral include:
- Unintended weight loss or low body weight
- Poor oral intake or refused meals
- Pressure injuries or poor wound healing
- Dysphagia (difficulty swallowing) or chewing problems
- Abnormal labs, such as low albumin or prealbumin
Documentation and the Interdisciplinary Team
Document observations that are objective, factual, and timely in the medical record — record what you observe ("ate 25% of lunch"), not opinions. The CDM contributes nutrition findings to the interdisciplinary team (IDT), which builds and updates each resident's care plan. Clear, continuous documentation is also what surveyors review for compliance.
During admission, a CDM completes a brief tool that flags a new resident as nutritionally at risk. What is the CDM's correct next step?
Which sequence correctly lists the four steps of the Nutrition Care Process?
Which entry is the MOST appropriate nutrition documentation for a CDM to place in a resident's medical record?