Saturday, April 12, 2014

So what does the nutrition progress note look like?

Remember the old days with paper medical records??
Usually at the end of a workshop or training on the Nutrition Care Process (NCP) and International Dietetics and Nutrition Terminology (IDNT) the question may what does the nutrition progress note look like??  And the usual answer "it depends" on your charting system is accurate--- however entirely unsatisfying.

When we first rolled out the NCP and IDNT in the United States, we began thinking about using a documentation format that was tailored to the steps in the nutrition care process:  ADIME (just taking the first letters of each of the steps (A=Assessment, D=Diagnosis, I=Intervention, and ME=Monitoring and Evaluation).  We began testing it at the first two facilities (See link to article below).

We quickly found out that while this concept was appealing and worked well for the initial nutrition progress note, it was far from ideal when you tried to use the same ADIME format for the follow-up note.  The question arising when writing the follow-up note was "where do you put the results of the M&E planned in the first note?"  In the M&E section of the follow-up note?? Or somewhere at the beginning of the follow-up note, perhaps in the Assessment section?

Then the concept was shortened to ADI, which left the ME to be placed where it made the most the end of the first note (e.g.  ADIME) when the ME is used only to identify what will be evaluated in the future.  However the results of the ME indicators selected in the original progress note would logically be included in the first part of the "reassessment", now in the A portion of the ADI format for the followup note. However, this concept became very confusing about how to best explain the connection between A and M&E.  This situation
lead to including the words Assessment/Re-Assessment in the NCP model that was published in 2008 and clearer graphics were used in presentations describing the connection between M&E and Assessment in the NCP and IDNT.  After discussing this more and thinking about the impact of electronic health records, the Academy committees determined that creating a new format for nutrition progress notes might not be the most successful strategy.

Instead we focused our efforts on showing how the NCP and IDNT terms would be incorporated into the various charting formats.  Specifically focusing on working with electronic health records companies to identify formats for "click and pick" systems where the terms were automatically built into E H R templates.  Several leading companies in the US licensed the terms and one built out a template for dietetics for the at least two (diagnosis and intervention) steps of the NCP.  Another system identified placemarkers for where the nutrition components (e.g. nutrition diagnoses and nutrition interventions) would be placed into existing patient education components.  Work also began on creating a toolkit to help dietitians work effectively with their own institutional electronic health records staff and process.

In addition, several cases were developed and posted on the website demonstrating how the same patient information could be incorporated into several of the popular charting formats:  Narrative, SOAP, and ADI.  This was intended to show dietitians that the NCP and IDNT provided underlying principles, concepts and terminology that would be used regardless of the medical record documentation systems used.  In addition, toolkits were developed for specific patient populations that included cases and example medical record documentation.

The Bottom Line:  What does the note look like?  It will often be quite similar to ones that you write now--BUT.

  • will incorporate the logical thinking used to identify the nutrition diagnosis (using the IDNT terms for nutrition diagnosis) 
  • will include the components of one or more PES statement(s):   e.g., Problem (Diagnosis), related to Etiology (root cause for nutrition problem/diagnosis) as evidenced by S (signs and symptoms data from assessment that substantiates your selection of the nutrition diagnosis and etiology)  
  • your description of the intervention will use the terms from the IDNT intervention term list  
  • will likely have more clearly identified the indicators (from the IDNT Assessment/Monitor and Evaluation term list) that you intend to use for M&E to determine whether your current treatment plan/recommendations are effective
  • may be shorter, more concise, and show a clearly described rationale for your nutrition treatment plan or recommendation
It will NOT include the term numbers and designations from the IDNT (those are only in the background for computer programmers to use to ensure that the databases identify the term correctly).  
  • If you have electronic health records the codes will be the computer language that is used to link the terms together across your patient populations.  
  • If you are doing research the codes will allow everyone to see the definition of the data that you are collecting. 
  • If you are doing Quality Improvement, the codes will ensure that you are collecting data from the records using the definitions provided in the IDNT reference manual.  
Links to resource materials

Implementing Nutrition Diagnosis, Step Two in the Nutrition Care Process and Model: Challenges and Lessons Learned in Two Health Care Facilities  Pubmed ID 16183367

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