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

Abstract

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.

Online training introduces a novel approach to the Dietetic Care Process documentation

“…Israeli RDs work in multidisciplinary teams within geriatric LTCFs; however, documenting treatment in collaboration with other health‐care professionals was identified as a difficulty. Others have reported similar outcomes, emphasising the need for additional practice in this step of the DCP.…”

The accuracy and consistency of nutrition care process terminology use in cases of refeeding syndrome

“…The mismatch between the diagnosis of ‘Malnutrition’ and reducing intake as an intervention, indicates some additional misunderstanding that the diagnosis, interventions and goals need to be interrelated. This disconnect was also seen in an American institution with limited documentation regarding nutritional steps and relationships between diagnosis and interventions and in a review of dietetic notes completed by Swedish dietitian nutritionists . Along with guided computer programs, readily available NCPT manuals and NCP champions may assist in the correct use of the NCPT .…”

“…To support these four processes, and to assist in standardising vocabulary, the Nutrition Care Process Terminology (NCPT) was also developed. A key benefit of using both the NCP and NCPT is the consistent formulation of nutrition diagnoses, otherwise known as PES statements, incorporating the problem (P), aetiology (E) and signs and symptoms (S) experienced by a patient . Nutritional diagnostic terms, incorporated within NCPT, are utilised to formulate the problem component of PES statements.…”

The Nutrition Care Process Terminology: Changes in perceptions, attitudes, knowledge and implementation amongst Australian dietitians after three years

“…The Nutrition Care Process (NCP) is a framework designed to assist dietitians in delivering high‐quality nutrition care. The framework is a four‐step process including nutrition assessment, diagnosis, intervention and monitoring and evaluation . Following the introduction of the NCP, a standardised language known as the International Dietetics and Nutrition Terminology (IDNT) was developed to provide dietitians with consistent terms to use throughout nutrition assessment, diagnosis, intervention and evaluation .…”

“…The NCPT aims to increase documentation consistency and allow the specific identification of nutrition issues in relation to, but set apart from, medical diagnoses. In addition, the terminology may provide clear and interpretable nutritional information to other allied health professions and allow for effective ongoing evaluation of health outcomes . Use of the NCPT is not mandatory for dietitians within Australia but is highly recommended by the Dietitians Association of Australia (DAA).…”