• Purpose
• To establish the policies, procedures and guidelines concerning the management and       operation of the Clinical Nutrition Out patient Clinics.
• To ensure proper administration of Nutrition care to all Clinical Nutrition Out patients.
  
• Definitions
• Nutrition Care Process - a method for Clinical Dietitians applying standardized  process   for providing care and standardized language in making decisions and provide high quality  nutrition care.
• Nutritional Assessment – to identify patient’s nutritional problems and high risk  patients who need special attention as a basis for nutritional care plan. It includes  collection and analysis of anthropometric, biochemical, clinical, dietary, and  psychosocial  data as well as consideration of the planned therapeutic management.
  
• Policy statements
• To define the relationship of Ambulatory Care Services with the Department of Clinical Nutrition Services.
• To establish and set forth in writing as far as practical, definite policies and regulations for Clinical Dietitians with other professional and non- professional employees in Ambulatory Care Centre.
• To establish written policies and guidelines for routine management for the Clinical Nutrition Outpatient Clinics.
• To institute and maintain good inter-departmental relationships.
  
• Procedures
• The function of Clinical Nutrition Outpatient Clinics is to provide appropriate  nutritional care through one-on-one or group-counseling sessions depending upon the  priorities identified to eligible patients properly referred to Clinical Nutrition Outpatient  Clinics in compliance with Strategic Plans, and established Policies and Procedures.
• The Clinical Dietitian functions as a consultant on the healthcare team. Counseling is   available for, but not limited to, the following areas for all ages (Pediatrics and Adults):
1. Breastfeeding
2. Cancer and immune compromised
3. Diabetes
4. Gastrointestinal disease
5. Metabolic disease
6. Food Allergy
7. Heart disease
8.  High blood pressure
9. High cholesterol
10. Home tube feeding
11. Pregnancy
12. Renal disease
13. Weight control & Weight loss.
14. Oncology
15. Post Gastric Bypass
• The Clinical Dietitian provides outpatient services to all patients requiring nutritional intervention and involves:
1. Anthropometric information
2. Laboratory information
3. Nutrition history including food allergies and medication
4. Medical concerns
5. Developing, implementing, and documenting an individualized plan
6. Analyzing subjective and objective information
• Providing nutritional counseling and education to patients and their caregivers, including   information on modified diets and food-drug interactions, and evaluation of the  effectiveness of counseling based on objective information when possible.
• All Clinical Dietitians shall document relevant information regarding patient’s adherence  to the prescribed diet via electronic system (QuadraMed).
• Official documentation via electronic system should follow the latest Nutrition Care  Process format of American Dietetic Association: Assessment, Diagnosis, Intervention,  Monitoring, and Evaluation (ADIME).
• Recommended diet based on nutritional assessment shall be coordinated with the  attending consultant and nurse.
• Clinical Dietitian shall provide individualized diet counseling with written instructions  /diet guides.
• Whenever possible family members should be included in the development of nutrition  care plan and education regarding patient’s recommended diet.
• Eligibility of Patients for Clinical Nutrition Outpatient Clinics at King Abdulaziz  Medical City-Jeddah:
1. Codes for Eligibility to treatment and the Coverage codes as per APP: 1429-01     “Patient Registration & Admission”.
2. Patient Services (Registration) should follow the current policy of eligibility.    APP: 780-07 "Determining Eligibility for Medical Care & Admission").
• Patient Categories: Patients treated in Clinical Nutrition Outpatient Clinics will fall into     one of four categories:
1. New Referrals (NP)
2. Clinic follow-up appointments (FU)
3. Post-discharge follow-up appointments (PDFU)
4. Walk-in Patients (WP)/Over booking (OB)
•  Patient Information & Identification:
1. It is the responsibility of Clinical Dietitians to ensure the proper identification of patients being treated, by the routine checking of patients' names, age and the treatment being provided.
2. When there are changes in information such as change in status, change of address, or telephone number, the patient must be referred to the Registration Office-Patient Services to update the data on computer.
3. If there is doubt about the true identity of the patient presenting for treatment, the Department of Patient Relations should be informed immediately. 
4. Clinical Nutrition Outpatient Clinics in Other Locations:
    
   Chief Clinical Nutrition Services will be responsible for ensuring that Clinical Dietitians,  who have scheduled their leave, have arranged for either Blockage or Coverage of their  Outpatient Clinics in other locations, such as Protocol (VIP) Clinics, Business Center  Clinics, etc.
•  Emergency Leave/Rescheduling Clinics/Cancellation of Clinics:
1. It is the responsibility of Chief Clinical Nutrition Services to see that adequate coverage is maintained at all times. However, in exceptional circumstances when it is unavoidable and when no alternative Clinical Dietitian is available, the rescheduling of patients must firstly be justified by Chief Clinical Nutrition Services, submitted for the approval of the Executive Director, Operation Services or his designee, and signed by the Director of Ambulatory Care Services.
2. Rescheduling may be agreed, provided the charts of all patients to be rescheduled are reviewed by the attending Clinical Dietitian assigned by Chief Clinical Nutrition Services to ensure that rescheduling will not compromise patient care.
3. The Clinical Dietitian must ensure any re-scheduled patient has sufficient diet supplements to allow a deferred appointment.
4. The list of patients can then be forwarded to the Patient Information Center  Supervisor (Patient Services) to contact the patients for rescheduling.
5. An alternative Clinical Dietitian must see any patient who cannot be contacted by Patient Services on the date his/her appointment was originally scheduled.
• Attendance at Conference and Symposia:
1. Requests to close all Clinical Nutrition Outpatient Clinics to permit as many Clinical Dietitians as possible to attend a local conference or symposium are not acceptable.
2. If Clinical Nutrition Department is hosting the activities, it is acceptable that all Clinical Dietitians block their clinics three months ahead.
• Clinical Dietitians Attendance in Scheduled Clinics:
1. Clinical Dietitians are expected to attend clinics on time and not leave before all scheduled patients are seen. If the Clinical Dietitians anticipates a delay in his/her arrival, he/she should advise the Back up coverage Clinical Dietitian by telephone.
• Clinical Nutrition Outpatient Clinics Scheduling:
1. The time allocated for the new patients and follow up will be according to the    recommendation of the Clinical Dietitians who is covering the clinics. 
2. All clinics must start on time regardless of the time allocated for the new or follow up patients. If the Clinical Dietitians does not arrive thirty (30) minutes after the scheduled clinic time, the Clinic Nurse Co-Coordinator/Nurse Manager should report this as per regionally applicable process. 
3. All clinics must finish on time regardless of the time allocated for the new or follow up patients. Habitually late finishing Clinical Dietitians are asked to reduce clinic slots.  If required, an additional clinic may be created to allow adequate time to see booked patients.
• During work days from Saturday to Wednesday:
  Time Open time First appointment Last appointment Finish time
  Morning 8:00am 8:30am 12:15am 12:30pm
  Afternoon 1:00pm 1:00pm 4:30pm 5:00pm
• During Holy Ramadan days from Saturday to Wednesday:
  Time Open time First appointment Last appointment Finish time
  Morning 10:00am 10:00am 12:15pm 12:30pm
  Afternoon 1:00pm 1:00pm 3:00pm 4:00pm
• Booking Patient into Clinical Nutrition Outpatient Clinics:
1. Each clinic will be structured by Patient Services
2. Numbers of appointment slots for New Patients (NP) are Three (3).
3. Numbers of appointment slots for Follow Patients (FU) are Seven (7).
4. Numbers of appointment slots for Walk-in/Overbooking are Two (2).
• Clinical Nutrition Outpatient Clinics with Long Waiting Lists for Appointments:
1. Patient Services will be responsible for producing Monthly Report indicating those Clinical Nutrition Outpatient Clinics with longer waiting time for appointments, i.e. in excess of three months.
2. The report will be distributed to the Chief Clinical Nutrition Services for his/her review, and for submission of his/her proposals to the Director of Ambulatory Care Services, explaining action taken to reduce the waiting time for appointments in those Clinics.
• New Referral of Patients from Clinical Dietitians to another Specialty:
   
  When a patient is referred from Clinical Nutrition Outpatient Clinics for  treatment by Clinical Dietitians to another specialty, a regionally applicable  referral form (Consultation Request and Report Form, Oracle#: 116174) is required and must be completed for the patient to be seen.
•  Screening Patients Charts and Referral for Clinical Nutrition Outpatients:
1. Physician should fill up the Clinical Nutrition Referral Forms
2. All patients shall be screened by Nursing Staff.
3. Prior to patients being referred to Clinical Nutrition Outpatients, members of the      Nursing Staff will ensure that all patients are screened to establish their:
1. Identity     
2. Vital signs
3. Last lab tests
4. Height and Weight
•  Proper communication between Physicians and Clinical Dietitians at the time of    arranging an outpatient referral. This will avoid inappropriate referrals that could    be disappointing for patients, and this will save patients and their families from    futile repeat hospital visits.
• The referral of hospital employees and their eligible dependents to Clinical    Nutrition Outpatients will be co-coordinated by the Physician in the Employee    Health Clinic.  Appointments will not be scheduled in Clinical Nutrition     Outpatients without the proper referral from Employee Health Clinic.
• Nursing Services for Clinical Nutrition Outpatients Clinics:
1. Clinical Nutrition Outpatients Clinics will be covered by Clinical Dietitians and    Nursing Staff assistants:
2. The assistant role includes but, not limited to:
1. Arranging files according to the appointments 
2. Taking Height and Weight
3. Printing addressograph stickers as required
4. Entering initial screening and assessment data to the computer for each        patient.
• Post Discharge and Clinic Follow Up Appointments:
1. Any inpatient discharged from King Abdulaziz Medical City-Jeddah, whom the treating Clinical Dietitians needs to see again, will be given an appointment for follow-up treatment.
2. Unless a specific appointment date is necessary for follow-up, Clinical Dietitians are encouraged to indicate a range of days/weeks for a follow-up appointment (for example 5-7 days or 3-4 weeks).
3. Patient Relations for Clinical Nutrition Outpatients Clinic:
1. Patient Relations Officers have a key role to play in Clinical Nutrition Outpatients Clinics, in addressing and solving problems as they arise in a timely manner.
2. Patients with a problem will be referred directly to the Patient Relations Officer.
4. Patients Attendance for Clinical Nutrition Outpatients Clinics:
1. To avoid overcrowding and congestion, patients should be encouraged to attend the Clinical Nutrition Outpatients Clinics no more than 15 minutes prior to their scheduled appointment time.  
2. Patients who attend late for their appointment in excess of 25 minutes will usually be rescheduled for another appointment, unless it is agreed with the Clinical Dietitian to accommodate the patient in the same clinic.
5. Did Not Attend (DNA - No Show) for Clinical Nutrition Outpatients Clinics: 
1. Patients who fail to keep an appointment (DNA) will not be accepted in Clinical Nutrition Outpatients Clinics as walk-in patients.  The Clinical Dietitians will review the medical records of these patients, and decide whether the patient should be given a routine rescheduled appointment or discharged. 
6. Patient Discharge from Clinical Nutrition Outpatients Clinics:
1. Patients should be discharged by Clinical Dietitians as soon as thei  medical and nutrition condition/status no longer needs Clinical Dietitians care except:
1. Patients on permanent Enteral feeding such as Nasogastric tube feeding (NGT)/ Percutaneous Endoscopic Gastrostomy (PEG) tube feeding
2. Oncology patients
3. Patients with Metabolic diseases
4. Failure to thrive patients who met the follow criteria:
1. (Pediatric patient): If patient weight for height in between the 10th & 90th % with no dietary problems.
2. (Pediatric patient): Patient who is non  compliant for three consecutive follow up visits.
3. Pediatric patient): Patient who is unable to attend the three consecutive follow up               appointments (except if admitted in the hospital).
5. (Adult patient): Patient who is non-compliant for three consecutive follows up visits.
6. (Adult patient): Patient who is unable to attend the three consecutive follow up appointments             (except if admitted in the hospital).
7. (Adult patient): Patients who have been assessed, treated and educated that are able to follow dietitian's advice at home without further assistance from Nutrition service.
2. A brief consultation sheet should be written and a copy given to the     patient to take with him/her at the last appointment.
    4.27.3. An appropriate supply of discharge take home supply (if needed) should      be provided.       
    4.27.4. In the event problems are encountered or the patient resists        discharge, the patient will be referred to the Patient Relation Officer.
3. The issuance of enteral formula both for adult and pediatric patients:
1. The Clinical Dietitian should identify the nutritional condition and requirements of the patient.
2. The Clinical Dietitian will identify the eligibility status of the patient.
3. The Clinical Dietitian should use patient’s identification official card to     make sticker label or addressograph must be placed in the Take Home Supply Form.
4. The Clinical Dietitian must clearly put the oracle number of the product     and specific number of cans or boxes based on the requirements of the     patient.
5. The Clinical Dietitian should issue limited to 1 month for those eligible     Jeddah residents, 2 months for those eligible outside Jeddah residents.
6. The eligible patient will take the completed original take home supply     form signed by Clinical Dietitian and present to the Central store staff.     
7. The Clinical Dietitian will take the second copy to be endorsed to Admin     Assistant of the Clinical Nutrition Department.
8. The Central store staff should verify the signature of the Clinical Dietitian     by comparing in the lists of updated Clinical Dietitians specimen signature    which will be provided by the Clinical Nutrition Department.
• Equipment/forms
• Outpatient Appointment Slip
• Dietitian’s Referral
• Quadramed computer system
• Consultation Request and Report Form, Oracle#: 116174
• Take Home Supply Form
• Addressograph White Card
• Addressograph machin

• Related references

Unified Policy & Procedures for Outpatient Services, APP Number: 1424-04