Thursday, January 1, 2015

Just do it!!! NCP and IDNT can be implemented without an electronic health record.

Dietitians who completed the MEDNA survey wanted to know if it was necessary to have an electronic health record before implementing the Nutrition Care Process.  Good news....there is no need to wait for implementation of an electronic health record to start using the Nutrition Care Process and standardized language.  They both can be implemented with or without electronic health records.

Dietitians can use the nutrition care process to guide their thinking process and approach to nutrition care regardless of type of medical record being used. Often some (but not all) the activities outlined in the Nutrition Care Process are already being done by the dietitian.  The one step that may be missing in the past is the Nutrition Diagnosis step.  This is the step where dietitians formally define the nutrition problem(s) that they will be addressing.  The activity is summarized in a Problem-Etiology-Signs and Symptoms (PES) statement.

Healthcare institutions have policies and procedures that guide the type of documentation that dietitians can enter in the paper medical record as well as what section of the medical record the documentation is stored.   Documentation can be structured in a variety of formats.  Dietitians may find it easier to ensure that all the steps of the nutrition care process are documented if the documentation structure follows the nutrition care process.

Nutrition Care Process steps and standardized language can be incorporated into a variety of nutrition progress notes:  Narrative, Subjective-Objective-Assessment-Plan (SOAP), Subjective-Objective-Assessment-Intervention-Evaluation-Response (SOPIER) Problem-Intervention-Evaluation (PIE), Assessment-Diagnosis-Intervention (ADI) or,Assessment-Diagnosis-Intervention-Monitoring and Evaluation (ADIME). or FOCUS notes with separate data, action and response for each "focus".
Examples showing the information in Narrative, SOAP and ADIME formats are posted on the Academy website.  While some information is available to all, these examples are currently only available for Academy members.

Dietitians may also have separate templates for different types of documentation.  For example they may have a separate nutrition assessment form that collects all the data used in the nutrition assessment.  This form may be stored in a separate part of the medical record, just as the laboratory reports or radiological reports are stored separate from the medical progress notes.  See the previous blog about where the activities of each of the nutrition care process steps might be included in the various progress note formats: What Nutrition Progress Notes look like or Form follows function.  Toolkits are available for purchase that include examples of progress notes.

  But the biggest benefits occur when the standardized language is embedded in electronic health record software and the information entered in the progress note is collected as data that can be "counted" and reported.  When the terminology is embedded in an electronic health record, the E H R templates can prompt the dietitian for common data entries,  the data from the E H R can be summarized into reports and provide data for dietitians to use in evaluating the outcomes and characteristics of their nutrition care.  Multiple templates can be created with "smart" applications that assist dietitians as they provide care.

BOTTOM LINE:  You can start using NCP and standardized terminology any time, however the biggest benefits will occur when the electronic health records incorporate the terminology and process into documentation templates.

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