We have a love-hate relationship with technology...especially Electronic Health Records (EHR). It would be nice if someone just came up with the perfect answer for how to incorporate NCP into an EHR. But, there are almost as many ways to incorporate the Nutrition Care Process and terminology into the E H R as there are dietitians. You can start incredibly simple or it may require extensive programming by informatics specialists. Your organization needs to determine what will best meet your needs.
On the simplest end of the continuum, a template can be developed with standard headings with "free text boxes" to prompt the dietitian as they write their progress note. As shown below, the dietitian then simply types in the data and information just as he/she might write a note long-hand but uses the terminology as appropriate. Sample headings shown below:
- Monitoring and Evaluation Data (Follow-up Note only)
- Nutrition Diagnosis
- Status of Previous Nutrition Diagnosis (Follow-up Note only)
- Nutrition Prescription
- Nutrition Intervention
- Plan for Monitoring and Evaluation
On the other end of the continuum would be the capability to program decision support prompts to help the dietitian enter patient care, similar to what the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) system does. It automatically incorporates the data fields, data terms for Nutrition Diagnosis, Nutrition Intervention, and Monitoring and Evaluation. And it "prompts" the dietitian with the most common etiologies, signs and symptoms and intervention to match the nutrition diagnosis/etiology. This type of "smart" system will yield the most benefit in terms of saving time and allowing the users to create meaningful reports and analyze data to answer key questions about outcomes.
The website contains a number of short videos that describe how the ANDHII works so a person can visualize the potential capabilities. The best video to start with might be the overview of the Smart Visit. When you see the demonstration of the Nutrition Diagnosis you will see that ANDHII automatically pre-populates suggestions for etiologies and signs and symptoms.
The solution for your organization is likely somewhere in between these two extremes. If you need help learning about how to work with electronic health records a toolkit (one per institution) was created for dietitians is available in the Academy "shop".
Please share your experiences in incorporating both NCP and the terminology into electronic health records!!
Murphy, W, Steiber, A. A New Breed of Evidence and the Tools to Generate It: Introducing ANDHII
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