Evaluation of a Nutrition Care Process‐based audit instrument, the Diet‐NCP‐Audit, for documentation of dietetic care in medical records

Lövestam, Elin; Orrevall, Ylva; Koochek, Afsaneh; Karlström, Brita; Andersson, Agneta

doi:10.1111/scs.12049

Cited by 17 publications

(23 citation statements)

References 27 publications

(48 reference statements)

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“…As an additional reliability test of the instrument in the present study, four of the authors audited a sample of 15 dietetic notes (10%). Comparisons were made regarding the total score of each dietetic note and its placement in quality levels A, B or C, showing Krippendorff's α of 0.74 and 0.82, respectively, which was considered high reliability and supported the earlier reliability results …”

Section: Methodssupporting

confidence: 54%

“…It was based on an earlier audit instrument, developed and validated in the US context regarding to the older six‐step NCP . The instrument was adapted to the four‐step NCP and for use in the Swedish context, and validated in a previous study . This validation included a content validity test where five experienced dietitians rated the instrument as having excellent validity and clarity, and inter‐ and intra‐rater reliability tests that showed moderate to strong reliability.…”

Section: Methodsmentioning

confidence: 99%

“…The maximum total score is 26 points, and to interpret the result of the instrument, depending on total score of the reviewed dietetic note, the note is placed into one of the quality levels A (high score, 20–26 points), B (medium score, 13.5–19.5 points) and C (low score, 0–13 points). The desired result would be as large a proportion as possible of the audited records in level A …”

Section: Methodsmentioning

confidence: 99%

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Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement

Lövestam

Orrevall

Koochek

et al. 2014

Nutrition & Dietetics

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Aim: High-quality documentation in patient records is essential for patient safety and plays a prominent role in the delivery and evaluation of dietetic/nutrition care. We aimed to evaluate dietitians' documentation in patient records according to the four steps in the Nutrition Care Process: assessment, diagnosis, intervention and monitoring/ evaluation. Methods: A retrospective audit of 147 systematically collected outpatient dietetic notes from primary care centres and hospitals in central Sweden was performed using a validated audit instrument. The instrument was used to assess the documentation of 14 items: 10 items focusing on the Nutrition Care Process steps and four items on language clarity and structure, with a maximum total score of 26 for each dietetic note. The notes were divided into three different quality levels, A (high score), B (medium score) or C (low score). Comparisons were made between notes from primary care and hospitals. Results: The audit showed that the majority of the notes were placed at level B, scoring 13.5-19.5. Only 3% of the notes scored higher than 19.5. The most frequently documented items were intervention (90%), evaluation (70%) and nutrition problem (56%), whereas the least documented items were nutrition prescription (15%), goal of intervention (9%) and connection of problem-etiology-symptom (5%). Flaws in lingual clarity were common (72%). Primary care notes received higher scores than those from hospitals. Conclusions: The audit shows that Swedish dietetic documentation needs to be improved, for example, by further training and education in the Nutrition Care Process and its standardised terminology.

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Section: Methodssupporting

confidence: 54%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement

Lövestam

Orrevall

Koochek

et al. 2014

Nutrition & Dietetics

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“…; Ibrahim ; Lövestam et al. ), this study has addressed questions about how the language used in dietetic notes omits both the dietitian and the patient from the dietetic note, and how this might affect the patient‐centredness of the notes. In this paper, we have discussed objectification of the patient and the ostensible objectivity of the clinician, which has previously also been taken up as criticism of discourses in health care (Foucault ; Donnelly ; Lawler ; Mead and Bower ).…”

Section: Discussionmentioning

confidence: 99%

The power of language on patient‐centredness: linguistic devices in the dietetic notes of patient records

Lövestam

Fjellström

Koochek

et al. 2014

Int J App Linguistics

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In this paper, 30 notes written by Swedish dietitians in patient records are analysed, inspired by Critical Linguistics and Critical Discourse Analysis. Focusing on linguistic devices such as agency sources and evidential markers, we describe how patients are constantly referred to only in terms of the institutional patient role, or not referred to at all, through different techniques such as nominalization and passive verbs. The dietitians writing the notes are even more absent from the text, as they almost never refer to themselves as persons in the dietetic notes. There is a stated ambition in health care to provide patient-centred care and a collaborative patient-clinician relationship. However, we suggest that there might be a need for more person-centred language in dietetics.I denna artikel har 30 journalanteckningstexter från svenska dietister analyserats med en metod inspirerad av kritisk lingvistik och kritisk diskursanalys. Genom att fokusera på språkliga mönster, som val av aktörer eller vilka anföringsverb som används, visar vi hur patienten konsekvent endast refereras till i sin institutionella roll som patient, eller inte refereras till över huvud taget. Detta sker via olika tekniker som nominalisering och passivisering. Dietisterna som skrivit journalanteckningarna är ännu mer frånvarande i texterna, då de i stort sett aldrig refererar till sig själva som personer i journalanteckningarna. Det finns en uttalad ambition inom hälso-och sjukvården att tillhandahålla patientcentrerad vård med en samverkande relation mellan patient och kliniker. Vi ser dock att kan finnas behov av ett mer personcentrerat språk inom dietetikens dokumentation.Nyckelord: Patientjournal, dietistanteckningar, patientcentrerad vård, hälso-och sjukvårdsdiskurs, medicinsk diskurs bs_bs_banner

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“…Atualmente, os nutricionistas em muitos países têm mostrado grande interesse no NCP e estão buscando implementá-lo (71)(72)(73)(74)(75)(76)(77) .…”

Section: Dietetics (And)unclassified

Carga de trabalho do nutricionista clínico: estudo de tempo e movimento contínuo em unidades de internação hospitalar

Oliveira¹

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Evaluation of a Nutrition Care Process‐based audit instrument, the Diet‐NCP‐Audit, for documentation of dietetic care in medical records

Cited by 17 publications

References 27 publications

Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement

Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement

The power of language on patient‐centredness: linguistic devices in the dietetic notes of patient records

Carga de trabalho do nutricionista clínico: estudo de tempo e movimento contínuo em unidades de internação hospitalar

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