Documenting the status of Nutrition Diagnoses as patient care continues
One of the key decisions that you will make is determining the appropriate method for documenting progress in nutrition diagnoses based upon your patient/client population.
The choices for documenting the status of a nutrition diagnosis included in the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) are as follows:
•
New
•
Continued
•
Resolved
•
Removed
However, in some cases the dietitian may want to know more than just whether it was continued or resolved, they may want to indicate directionality for a continued nutrition diagnoses for example, using a three way description of improved, declined/worsened, or no change.
One approach, developed by UPMC Presbyterian Shadyside that accomplishes this directionality uses these terms:
At this point, there is no clear right or wrong answer to how your institution chooses to record the current status of a nutrition diagnosis.
As you are considering how you want to record your status, you may want to be thinking about the end result or type of reports that you want. With the increased use of electronic health records any data recorded in a systematic way can be pulled into a report with the assistance of information technology experts.
With either the system begin tested in the ANDHII or some other method such as that which was originally designed by UPMC Presbyterian Shadyside you will be able to generate a numerical percent of the number of nutritional diagnoses that were "resolved" and the number that were removed due to the change in patient condition.
However if you use the ANDHII system it will be difficult to know how to characterize those that are "continued" , e.g. whether they improved, stayed the same, or worsened.
Your report using the ANDHII data might look like:
Month_____
Total number of Nutrition Diagnoses identified ________
(Sum of all notes/records)
Total number of Nutrition Diagnoses resolved _________
(Sum of all notes/records
Average nutrition diagnoses per patient ______
(Sum/patients with notes/records)
% patients with at least one Nutrition Diagnoses resolved
Narrative list of TOP 10 nutrition diagnoses identified
Narrative list of TOP 5 nutrition diagnoses resolved
Narrative list of TOP 10 MEDICAL Diagnoses with nutrition diagnoses
May want to show Top 10 Medical Dx matched with top 1-2 Nutrition
Diagnoses for Medical diagnoses
Or it could be something like the following table which shows a total of those that improved added plus that were resolved and situations where the nutrition diagnoses was no longer appropriate (removed) where it was impossible to resolve/improve.
However, in some cases the dietitian may want to know more than just whether it was continued or resolved, they may want to indicate directionality for a continued nutrition diagnoses for example, using a three way description of improved, declined/worsened, or no change.
One approach, developed by UPMC Presbyterian Shadyside that accomplishes this directionality uses these terms:
• “Resolved”—nutrition diagnosis no longer exists because it has been addressed
• “Improvement shown/unresolved”—nutrition diagnosis still exists but signs/symptoms showing improvement. Patient/client making progress
• “No improvement/unresolved”—nutrition diagnosis still exists, little to no improvement shown, still appropriate for patient/client’s condition
• “No longer appropriate”—nutrition diagnosis is no longer exists because patient/client’s condition or situation has changed. The focus of nutrition interventions no longer supports the nutrition diagnosis
At this point, there is no clear right or wrong answer to how your institution chooses to record the current status of a nutrition diagnosis.
As you are considering how you want to record your status, you may want to be thinking about the end result or type of reports that you want. With the increased use of electronic health records any data recorded in a systematic way can be pulled into a report with the assistance of information technology experts.
With either the system begin tested in the ANDHII or some other method such as that which was originally designed by UPMC Presbyterian Shadyside you will be able to generate a numerical percent of the number of nutritional diagnoses that were "resolved" and the number that were removed due to the change in patient condition.
However if you use the ANDHII system it will be difficult to know how to characterize those that are "continued" , e.g. whether they improved, stayed the same, or worsened.
Your report using the ANDHII data might look like:
Month_____
Total number of Nutrition Diagnoses identified ________
(Sum of all notes/records)
Total number of Nutrition Diagnoses resolved _________
(Sum of all notes/records
Average nutrition diagnoses per patient ______
(Sum/patients with notes/records)
% patients with at least one Nutrition Diagnoses resolved
Narrative list of TOP 10 nutrition diagnoses identified
Narrative list of TOP 5 nutrition diagnoses resolved
Narrative list of TOP 10 MEDICAL Diagnoses with nutrition diagnoses
May want to show Top 10 Medical Dx matched with top 1-2 Nutrition
Diagnoses for Medical diagnoses
Or it could be something like the following table which shows a total of those that improved added plus that were resolved and situations where the nutrition diagnoses was no longer appropriate (removed) where it was impossible to resolve/improve.
