NUTRITION UNIT MONITORING TOOL MO-56 Nutrition Services: 400 points or 40% of Total Program Review Score A) District Points Score Nutrition Available Based on Office for Each Points Section available/Total Nutrition points available (400) Secondary Nutrition Education Provided 50 12.5% (25) Low Risk Secondary Nutrition Education (25) High Risk Secondary Nutrition Education 20 3.75% Breastfeeding Promotion and Support 20 5% Breastfeeding Peer Counselor Program 15 5% District Created Food Packages (999 Review) 15 3.75% Nutrition Education Materials 15 3.75% District Self Reviews “Nutrition”: 5 1.25% Orientation Checklist 20 5% (% Meeting Standard) Continuing Education: Competent Professional Authority (CPA) Nutrition Assistant (NA) Breastfeeding Peer Counselor (PC) 160 B) (Clinic) Chart Review Percentage for Documentation: 30 7.5% Breastfeeding Encouragement to Breastfeed Clinic Environment Supportive of Breastfeeding Breastfeeding Referral System in Place Breastfeeding Equipment 30 C) (Clinic) - Nutrition Education Observation (Certifications, low and 75 18.75% Clinic high risk secondary nutrition education contacts) Observation Anthropometric Equipment / Hematological Equipment 5 1.25% Anthropometric Observation 5 1.25% Hematological Observation 5 1.25% 90 D) (Clinic) Formula Tracking Log 5 1.25% & State Ordered Formula Tracking Food Log High Risk / Special Formulas/Medical Documentation Package 15 3.75% 20 E) (Clinic) Record Review Summary - 100 Points Total per Chart. 100 25% Record Highlighted Red OR Highlighted Black - Requires Corrective Action Training Review One clinic average <90% requires clinic specific training Two highlighted clinics <100% requires clinic specific training Three or more highlighted clinics <100% requires district-wide training
NUTRITION UNIT MONITORING TOOL MO-56 Nutrition Services: 400 points or 40% of Total Program Review Score A) District Nutrition Office Points Available for Each Section Score Based on Points available/Total Nutrition points available (400) Secondary Nutrition Education Provided Low Risk Secondary Nutrition Education High Risk Secondary Nutrition Education Breastfeeding Promotion and Support Breastfeeding Peer Counselor Program District Created Food Packages (999 Review) Nutrition Education Materials District Self Reviews “Nutrition”: Orientation Checklist Continuing Education: (% Meeting Standard) Competent Professional Authority (CPA) Nutrition Assistant (NA) Breastfeeding Peer Counselor (PC) 50 (25) (25) 20 20 15 15 15 5 20 12.5% 3.75% 5% 5% 3.75% 3.75% 1.25% 5% 160 B) (Clinic) Breastfeeding Chart Review Percentage for Documentation: Encouragement to Breastfeed Clinic Environment Supportive of Breastfeeding Breastfeeding Referral System in Place Breastfeeding Equipment 30 7.5% 30 C) (Clinic) - Clinic Observation Nutrition Education Observation (Certifications, low and high risk secondary nutrition education contacts) Anthropometric Equipment / Hematological Equipment Anthropometric Observation Hematological Observation 75 5 5 5 18.75% 1.25% 1.25% 1.25% 90 D) (Clinic) Food Package Formula Tracking Log & State Ordered Formula Tracking Log High Risk / Special Formulas/Medical Documentation 5 15 1.25% 3.75% 20 E) (Clinic) Record Review Record Review Summary - 100 Points Total per Chart. Highlighted Red OR Highlighted Black - Requires Corrective Action Training One clinic average <90% requires clinic specific training Two highlighted clinics <100% requires clinic specific training Three or more highlighted clinics <100% requires district-wide training 100 25%
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