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- Title
Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement.
- Authors
Lövestam, Elin; Orrevall, Ylva; Koochek, Afsaneh; Karlström, Brita; Andersson, Agneta
- 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.
- Subjects
SWEDEN; AUDITING; CHI-squared test; DIAGNOSIS; DIET therapy; DIETITIANS; MEDICAL needs assessment; NURSING records; PRIMARY health care; QUALITY assurance; RESEARCH funding; RETROSPECTIVE studies; DATA analysis software; ELECTRONIC health records; MANN Whitney U Test; KRUSKAL-Wallis Test
- Publication
Nutrition & Dietetics, 2015, Vol 72, Issue 1, p74
- ISSN
1446-6368
- Publication type
Article
- DOI
10.1111/1747-0080.12128