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Evaluation of N utrition C are P rocess documentation in electronic patient records: Need of improvement
Author(s) -
Lövestam Elin,
Orrevall Ylva,
Koochek Afsaneh,
Karlström Brita,
Andersson Agneta
Publication year - 2015
Publication title -
nutrition and dietetics
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.479
H-Index - 31
eISSN - 1747-0080
pISSN - 1446-6368
DOI - 10.1111/1747-0080.12128
Subject(s) - documentation , audit , medicine , clarity , intervention (counseling) , medical prescription , quality management , primary care , medical record , test (biology) , family medicine , medical emergency , emergency medicine , nursing , operations management , surgery , computer science , biochemistry , chemistry , management , economics , programming language , paleontology , management system , biology
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 N utrition C are P rocess: 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 S weden was performed using a validated audit instrument. The instrument was used to assess the documentation of 14 items: 10 items focusing on the N utrition C are P rocess 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 N utrition C are P rocess and its standardised terminology.