Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care

Abstract

Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals-nurses, physicians, advanced practice providers, pharmacists, and dietitians-identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization's Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software. (Nutr Clin Pract. 2020;35:12-23)

Nutrition Support Therapies on the Medication Administration Record: Impacts on Staff Perception of Nutrition Care

“…Implementation of the nutrition care process using a standardized, streamlined approach that accommodates ordering, documenting, and monitoring nutrition interventions in the EHR is recommended 24,30,31 . In addition to this institution, other US hospital systems have reported utilizing MAR and BCMA to order, administer, and document NST, including the Phoenix VAMC and Tampa General Hospital, among others 8,25,26,35,36 .…”

“…Several professional bodies have published documents related to best practices for NST and documentation of nutrition care. The 2016 American Society for Parenteral and Enteral Nutrition (ASPEN) consensus statements on safe practices for EN therapy recommend that the “EN order should be included in the patient's electronic medication profile to allow a pharmacist to review the EN order and patient medication profile and the pharmacist will assess: the appropriateness of the medication route of administration, the compatibility of medication with enteral formulas, and methods to optimize the medication regimen.” 30 In 2019, in recognition of issues surrounding fragmented EHR documentation of nutrition care, ASPEN published consensus recommendations for optimizing EHRs for nutrition care, which included enhancing documentation systems to support quality nutrition care 31 . In 2020, the Joint Commission issued National Patient Safety Goal NPSG.03.06.01 “Use Medicines Safely,” which states, “Record and pass along correct information about a patient's medicines, find out what medicines the patient is taking, compare those medicines to new medicines given to the patient, give the patient written information about the medicines they need to take, tell the patient it is important to bring their up‐to‐date list of medicines every time they visit a doctor.” 32 The recommendations by the American Society of Health‐System Pharmacists to have pharmacist verification and review of all dietary supplements and medications when patients are hospitalized further support the importance of diligence and care while prescribing, administering, and documenting NST 33…”

Consensus on the standard terminology used in the nutrition care of adult patients with chronic kidney disease

“…The standardization of the NCPT in electronic patient chart systems allows documentation in a structured format. Workflows and tools used in this task have been published for adult and pediatric practices 116 . Data entries with minimal free text (structured patient chart) allows for quick access, less ambiguity and more specificity, and confinement within evidence-based parameters.…”

Computer‐Assisted Prescription: The Future of Nutrition Care?

“…The experts of the American Society for Parenteral and Enteral Nutrition (ASPEN) have recently issued consensus recommendations for optimizing electronic health records for all aspects of nutrition care, from nutrition assessment, diagnosis, and care plan to intervention, monitoring, and evaluation. 23 Most institutions that wish to implement a digitalized system to aid nutrition management choose to either adapt their generic clinical information system (CIS) by customizing a module dedicated to nutrition or develop specific applications based on generic programs like Microsoft Excel spreadsheets. Several teams [24][25][26] have demonstrated that the use of a nutrition module with a generic CIS consistently improves delivery of nutrition prescriptions compared with an unassisted prescription.…”

“…Implementing a decision support system in the field of clinical nutrition requires a clear understanding of the nutrition care workflow from ICU care to posthospitalization follow‐up. The experts of the American Society for Parenteral and Enteral Nutrition (ASPEN) have recently issued consensus recommendations for optimizing electronic health records for all aspects of nutrition care, from nutrition assessment, diagnosis, and care plan to intervention, monitoring, and evaluation 23 …”