Referral by Licensed Medical Provider: A medical provider must provide a referral for clients receiving MNT services.

1. Percentage of clients with documentation of the medical provider’s referral to MNT.

Medical Nutrition Therapy Assessment: An LD will conduct an initial comprehensive nutritional assessment for all clients. The comprehensive nutritional assessment must include the following components: 

• Clinical history
• Physical examination
• Anthropometric measurements
• Diagnostic tests
• Functional assessment 
• Dietary assessment

2. Percentage of clients with documentation of a completed assessment conducted by an LD that includes the following components at a minimum:
   1. Clinical history
   2. Physical examination
   3. Anthropometric measurements
   4. Diagnostic tests as applicable 
   5. Functional assessment
   6. Dietary assessment

Nutrition Plan: Within 10 business days of the MNT assessment, the LD will develop a nutritional plan appropriate for the client’s health status, financial status, and individual preferences.

• The nutrition plan must include documentation of the following:
• The client's diagnosis
• The recommended services and course of medical nutrition therapy, including types and amounts of nutritional supplements and food
• The date of service initiation
• The planned number and frequency of sessions
• The signature of the LD who developed the plan

The LD will update the nutrition plan as necessary, but no less than twice per year, and will share the plan with the client, the client’s primary care provider (as applicable), and other authorized personnel involved in the client’s care.
 

3. Percentage of clients with a documented nutrition plan within 10 business days of the MNT assessment that includes the following components at a minimum:
   1. The client’s diagnosis
   2. The recommended services and course of medical nutrition therapy, including types and amounts of nutritional supplements and food.
   3. The date of service initiation
   4. The planned number and frequency of sessions
   5. The signature of the LD who developed the plan
       
4. Percentage of clients with documentation of a nutrition plan updated at least twice per year if the client has been receiving services for over 12 months.

Provision of Nutritional Supplements and Food Provisions: Where the agency provides medically necessary nutritional supplements and food provisions, staff will maintain written orders from the referring provider in the client record.

5. Percentage of clients receiving nutritional supplements or food provisions with written orders from the referring provider.

Discharge: When an agency discharges a client from services, staff must document a discharge summary in the client record that includes: 

• The date of discharge
• The reason for discharge
• Recommendations for follow-up 

Staff will provide this documentation to the prescribing provider and other multidisciplinary team members, as applicable.

6. Percentage of clients discharged from services during the measurement period with the following documentation components:
   1. Date of discharge 
   2. Reason for discharge
   3. Recommendations for follow-up
   4. Prescribing provider notified of discharge