Sunday, April 20, 2014

Nutrition Progress Notes: Form follows function

While the principle of "Form follows function" is widely used in architecture, it is equally applicable as we think about nutrition progress notes.  As we consider the optimal nutrition progress note format and content, it is important to think about the purpose of a nutrition progress note and the intended audiences.  While there may be slight differences in the target audiences between various practice settings, most can be grouped into the following target audiences
  • Healthcare Team Members (Physicians, Nurses, and Dietetics practitioners)
  • Accrediting Agencies, Regulatory bodies, and legal audiences
  • Patients (there is a growing trend to use the medical record as a communication tool with the patient)  
When we think about these target audiences we also think about what is important for each of them::
  • Continuity of care (from dietitian visit to dietitian visit, among physicians, nurse and other health care providers)
  • Description of and rationale for care (for legal purposes, so enable reviewers to make judgments about whether standards of care were met)
It is important that the nutrition progress note include a clear and concise description of exactly what care was provided, include the rationale or reason for the nutrition care provided or recommended, indicate the anticipated outcomes of care, and indicate the connection or relationship with other aspects of healthcare being provided, considered, or recommended.  The Nutrition Care Process is a logic based problem solving methodology and the IDNT is intended to provide the language that is precise, yet easily understood by the target audiences.

A set of questions was developed to evaluate the nutrition progress note to ensure that the logic of the NCP is captured in the written progress note  This work was originally published in 2005 by Nancy Hakel-Smith, Lewis and Eskidge and has since been adapted and posted on the Academy website in two versions...a simple version and version that can be "scored" to more clearly show improvement over time. The version that can be scored was adapted by Dee Pratt and Sherry Jones.   This questionnaire has also been adapted for international use in Sweden by Lovestam et al to evaluate and compare documentation of NCP in electronic patient records.  Scores from the 14 items used to evaluate the notes placed these notes into three different quality levels (high, medium and low).  These tools are valuable ways to check our documentation to ensure that our care is adequately described.  In some cases the areas for improvement are simply opportunities for clarity in documentation, in other instances this evaluation may highlight areas where the nutrition care itself may be improved.

We continually seek ways to improve our nutrition care and the documentation of the care to ensure that patients and clients receive the best possible care and have the highest possibility of achieving optimal health through nutrition.    

Links of interest

Hakel-Smith, Lewis and Eskridge. Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners.  JADA, 2005  PUBMED ID: 16183359

Academy Members Only Link to Brief Chart Audit Tool and Comprehensive Sample Chart Audit Tools:

 Lovestam, Orrevall, Koochek, Karlstrom, Anderson    Evaluation of Nutrition Care Process documentation in electronic patient records need improvement.  Scand J of Caring ScienceMay 2013 Abstract

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