WIC Nutrition Services Documentation
This policy memorandum identifies the purpose, necessary elements and outcomes for nutrition services documentation in the WIC Program. WIC nutrition services include nutrition assessment and risk assignment, nutrition education, breastfeeding support, food package prescription, referrals, and related follow-up. Quality documentation, which may be electronic or paper based, facilitates the delivery of meaningful nutrition services and ensures continuity of care for WIC participants.
The Food and Nutrition Service is issuing this policy memorandum to assist state agencies in the development of documentation policies and procedures that meet Federal documentation requirements (see Attachment I) and enhance the delivery of quality nutrition services. Establishing quality documentation policies and procedures improves program integrity and coordination with the health care community, and further builds on Value Enhanced Nutrition Assessment, WIC Nutrition Services Standards and WIC Nutrition Education Guidance. Quality documentation is critical for the continued success of the Program and supports the ongoing process of Revitalizing Quality Nutrition Services in WIC.
Nutrition Services Documentation Purpose
Documentation provides invaluable information for managing and evaluating services delivered. It is the primary means by which WIC staff communicate with each other about individual participants. Its purpose is to ensure the:
- quality of nutrition services provided by identifying risks and/or participant concerns, facilitating follow-up and continuity of care (enabling WIC staff to “pick-up” where the last visit ended by following-up on participant goals, reinforcing nutrition education messages, etc.); and
- integrity of the WIC Program through documentation of nutrition services data used for eligibility determination and WIC Participant and Characteristics reporting.
Elements of Quality Nutrition Services Documentation
WIC state agencies may adapt or develop a documentation process that works best for their unique operations. Although many WIC agencies utilize a medical model of documentation, this policy allows for the flexibility to adapt a public health model for documentation. While specific documentation processes may differ, there are key elements that must be incorporated into all documentation systems for effective and efficient documentation. All documentation systems must be:
- Consistent – establishes standards/protocols to which all staff must adhere;
- Clear – is easily understood (by other WIC staff) using documentation abbreviations, etc., as established by the state and/or local agencies;
- Organized – follows an established order (e.g., anthropometric data is located in the same place in each chart) and minimizes duplication;
- Complete – creates a picture of the participant, describes or lists the services provided over time, and outlines a plan for future services; and
- Concise – contains minimal extraneous information.
Nutrition Services Documentation Outcomes
A key outcome of nutrition services documentation is the capture of a complete picture of the participant’s visit in a manner that is easy to retrieve and review, enabling WIC staff to build upon and follow-up on prior visits. A summary page or participant profile is not a requirement of documentation. However, the participant file must be readily accessible and easy to review. The participant file in which information is documented may be electronic, hard copy, or a combination of the two.
Certain nutrition services data must be documented in the participant file:
- Assessment information
- All risks/needs identified through the assessment process
- WIC category and priority level
- Food package prescribed (to include medical documentation when required and rationale for food package tailoring, if done)
- Nutrition education* and referrals provided
- Follow-up activity plans and future visits
- An individual care plan for high risk participants (identified by the competent professional authority, per state agency protocols)
* Second or subsequent nutrition education contacts during a certification period that are provided to a participant in a group setting may be documented in a masterfile as per Federal WIC regulations (7 CFR 246.11(e) (4)).
Additional information relevant for continuity of care may include:
- Participant’s progress towards behavior change (if participant-identified goal was set at previous visit)
- Nutrition education delivery medium (e.g., group education, individual counseling) and information reinforcements used (e.g., handouts, video, pamphlet)
- Other pertinent information (e.g., participant’s readiness to change behavior; teaching strategy/counseling method)
Another outcome of quality documentation is the ability to track participants’ behavior change and other outcomes over time (both aggregate and individual). This provides perspective on the effect of the WIC Program on participants’ nutrition and lifestyle practices and serves as a tool for planning and identifying target areas for nutrition services.
Quality documentation is critical for the continued services of the WIC Program. To support state agencies in the development of documentation procedures, attached is a list of resources related to nutrition services documentation. In addition, attached are summary citations and language from WIC Program Federal Regulations, Policy Memoranda and Nutrition Services Standards associated with nutrition services documentation (Attachment I) and a listing of Nutrition Services Documentation Resources (Attachment II). State agencies should review this supplemental information when developing documentation policies and procedures.
PATRICIA N. DANIELS
Supplemental Food Programs Division