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Where Can I Find Resources for Medical Record Documentation?
FROM THE ACADEMY Question of the Month
Where Can I Find Resources for Medical Record Documentation?
T
HE HOSPITAL MEDICAL RECORD constitutes the only permanent record of a patient’s illness and treatment. At one time, dietitians routinely kept patient progress notes in dietary department files.1 In December of 1965, it was recommended that the progress notes of the patient’s medical record was the most appropriate place within the medical record for reporting on dietary consultation, and guidelines were released in 1966.1 The guidelines were later revised and included information on how narrative entries could be structured in the SOAP (subjective, objective, assessment, plan) format of medical record documentation.2 However, the guideline stated, “Regardless of format used, entries in the patient’s medical record should contain sufficient information to support the dietary assessment, to justify dietetic care, and to document the results accurately.”2 Medical record documentation over the years has included a variety of strategies in response to various influences. Ultimately, however, as noted from the beginning, the documentation method selected is determined by the institution where the dietitian practices. In 2003, the Academy announced the adoption of the Nutrition Care Process and Model in an article describing the complete Nutrition Care Process (NCP).3 The NCP is intended to provide nutrition and dietetics practitioners with a framework for critical thinking and decision-making. The NCP is not intended to standardize nutrition care for each patient/client, but to establish a standardized process for providing individualized care. Key to identifying
This article was written by Eleese Cunningham, RDN, of the Academy of Nutrition and Dietetics’ Knowledge Center Team, Chicago, IL. Academy members can contact the Knowledge Center by sending an e-mail to [email protected]. http://dx.doi.org/10.1016/j.jand.2015.06.008
1360
the unique contributions of registered dietitian nutritionists (RDNs) is the use of standardized terminology. Using standardized terminology in the context of medical record documentation allows RDNs in all settings to use the same words to describe things, which results in more precise and effective communication. The NCP consists of four steps: (a) Nutrition Assessment, (b) Nutrition Diagnosis, (c) Nutrition Intervention, and (d) Nutrition Monitoring and Evaluation. Some RDNs also use ADIME (A¼Assessment, D¼ Diagnosis, I¼Intervention, M¼Monitoring, E¼Evaluation). Regardless of format, quality documentation should include:
nutrition-related assessment data; a clear concise statement of nutrition diagnosis(es); a description of the nutrition intervention; and a description of nutrition monitoring and evaluation to identify patient/client outcomes.4
An update of the NCP focusing on documentation includes examples incorporating standardized terminology into documentation.4 Additional case studies, “Inpatient Critical Illness— Diabetes” and “Outpatient Weight Management,” are used in examples showing documentation for the same case study in a Narrative Format, a SOAP Format, and ADIME, reiterating the importance of content over documentation format. These examples can be found in the NCP 101 information on the Academy’s website at: http://www. eatrightpro.org/resource/practice/nutri tion-care-process/ncp-101/nutrition-careprocess-the-next-level. Use of a standardized terminology enables RDNs to move from documentation in paper medical records to an integral component of electronic health records. The profession is currently transitioning toward RDNs working in a team environment, providing interventions, and measuring improved outcomes via electronic health records.5
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
The tools below can assist the RDN in utilizing the Nutrition Care Process and helping ensure that critical data are captured and nutrition care documentation is included in databases and collected in a consistent way.
References 1.
American Dietetic Association. Guidelines for the therapeutic dietitian in making notations in the medical record. J Am Diet Assoc. 1966;49(3):215-216.
2.
American Dietetic Association. Guidelines for Recording Nutritional Information in Medical Records. In: Handbook of Clinical Dietetics. Chicago, IL: American Dietetic Association; 1981:113-118.
3.
Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003;103(8):1061-1072.
4.
Writing Group of the Nutrition Care Process/Standardized Language Committee. Nutrition care process part II: Using the International Dietetics and Nutrition Terminology to document the nutrition care process. J Am Diet Assoc. 2008;108(8):12871293.
5.
Grim J, Roberts S. The Clinical Nutrition Manager’s Handbook: Solutions for the Busy Professional. Chicago, IL: Academy of Nutrition and Dietetics; 2014:192-193.
Additional Resources Journal of the Academy of Nutrition and Dietetics Collection: Nutrition Care Process and Terminology. Accessed May 21, 2015. http://www. andjrnl.org/content/content/nutritioncare. The Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) is an online tool, available free to Academy members. Designed to guide dietetics practitioners through each step of the Nutrition Care Process. Find out more at: http://www.eatrightpro.org/ resources/practice/nutrition-care-process/andhii. The NCP Tutorial is a series of 15 videos. Each module is approximately 10 minutes long. The modules are free to everyone and available at: https://ncpt.webauthor.com/encpt-tutorials. Electronic Nutrition Care Process and Terminology (eNCPT) (formerly IDNT) launched in 2014. The eNCPT is a comprehensive guide for implementing the Nutrition Care Process using a standardized language and is available for purchase at: http://ncpt.webauthor.com.
ª 2015 by the Academy of Nutrition and Dietetics.
Where Can I Find Resources for Medical Record Documentation?
T
HE HOSPITAL MEDICAL RECORD constitutes the only permanent record of a patient’s illness and treatment. At one time, dietitians routinely kept patient progress notes in dietary department files.1 In December of 1965, it was recommended that the progress notes of the patient’s medical record was the most appropriate place within the medical record for reporting on dietary consultation, and guidelines were released in 1966.1 The guidelines were later revised and included information on how narrative entries could be structured in the SOAP (subjective, objective, assessment, plan) format of medical record documentation.2 However, the guideline stated, “Regardless of format used, entries in the patient’s medical record should contain sufficient information to support the dietary assessment, to justify dietetic care, and to document the results accurately.”2 Medical record documentation over the years has included a variety of strategies in response to various influences. Ultimately, however, as noted from the beginning, the documentation method selected is determined by the institution where the dietitian practices. In 2003, the Academy announced the adoption of the Nutrition Care Process and Model in an article describing the complete Nutrition Care Process (NCP).3 The NCP is intended to provide nutrition and dietetics practitioners with a framework for critical thinking and decision-making. The NCP is not intended to standardize nutrition care for each patient/client, but to establish a standardized process for providing individualized care. Key to identifying
This article was written by Eleese Cunningham, RDN, of the Academy of Nutrition and Dietetics’ Knowledge Center Team, Chicago, IL. Academy members can contact the Knowledge Center by sending an e-mail to [email protected]. http://dx.doi.org/10.1016/j.jand.2015.06.008
1360
the unique contributions of registered dietitian nutritionists (RDNs) is the use of standardized terminology. Using standardized terminology in the context of medical record documentation allows RDNs in all settings to use the same words to describe things, which results in more precise and effective communication. The NCP consists of four steps: (a) Nutrition Assessment, (b) Nutrition Diagnosis, (c) Nutrition Intervention, and (d) Nutrition Monitoring and Evaluation. Some RDNs also use ADIME (A¼Assessment, D¼ Diagnosis, I¼Intervention, M¼Monitoring, E¼Evaluation). Regardless of format, quality documentation should include:
nutrition-related assessment data; a clear concise statement of nutrition diagnosis(es); a description of the nutrition intervention; and a description of nutrition monitoring and evaluation to identify patient/client outcomes.4
An update of the NCP focusing on documentation includes examples incorporating standardized terminology into documentation.4 Additional case studies, “Inpatient Critical Illness— Diabetes” and “Outpatient Weight Management,” are used in examples showing documentation for the same case study in a Narrative Format, a SOAP Format, and ADIME, reiterating the importance of content over documentation format. These examples can be found in the NCP 101 information on the Academy’s website at: http://www. eatrightpro.org/resource/practice/nutri tion-care-process/ncp-101/nutrition-careprocess-the-next-level. Use of a standardized terminology enables RDNs to move from documentation in paper medical records to an integral component of electronic health records. The profession is currently transitioning toward RDNs working in a team environment, providing interventions, and measuring improved outcomes via electronic health records.5
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
The tools below can assist the RDN in utilizing the Nutrition Care Process and helping ensure that critical data are captured and nutrition care documentation is included in databases and collected in a consistent way.
References 1.
American Dietetic Association. Guidelines for the therapeutic dietitian in making notations in the medical record. J Am Diet Assoc. 1966;49(3):215-216.
2.
American Dietetic Association. Guidelines for Recording Nutritional Information in Medical Records. In: Handbook of Clinical Dietetics. Chicago, IL: American Dietetic Association; 1981:113-118.
3.
Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003;103(8):1061-1072.
4.
Writing Group of the Nutrition Care Process/Standardized Language Committee. Nutrition care process part II: Using the International Dietetics and Nutrition Terminology to document the nutrition care process. J Am Diet Assoc. 2008;108(8):12871293.
5.
Grim J, Roberts S. The Clinical Nutrition Manager’s Handbook: Solutions for the Busy Professional. Chicago, IL: Academy of Nutrition and Dietetics; 2014:192-193.
Additional Resources Journal of the Academy of Nutrition and Dietetics Collection: Nutrition Care Process and Terminology. Accessed May 21, 2015. http://www. andjrnl.org/content/content/nutritioncare. The Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) is an online tool, available free to Academy members. Designed to guide dietetics practitioners through each step of the Nutrition Care Process. Find out more at: http://www.eatrightpro.org/ resources/practice/nutrition-care-process/andhii. The NCP Tutorial is a series of 15 videos. Each module is approximately 10 minutes long. The modules are free to everyone and available at: https://ncpt.webauthor.com/encpt-tutorials. Electronic Nutrition Care Process and Terminology (eNCPT) (formerly IDNT) launched in 2014. The eNCPT is a comprehensive guide for implementing the Nutrition Care Process using a standardized language and is available for purchase at: http://ncpt.webauthor.com.
ª 2015 by the Academy of Nutrition and Dietetics.