Documentation of clinical services within health care systems has become increasingly significant because greater amounts of information are now required by accrediting agencies, third-party payers, researchers, and others in their evaluation of patient care and because of the increasing emphasis on patient outcomes. Given the multiple users who depend on health care information in the patient record, it is imperative that clinical nutrition practitioners implement a standardized nutrition care process and language to document comprehensively and communicate meaningful information concerning their role in improving patient outcomes. A body of work has led to the development and adoption of a standardized nutrition care process for the dietetics profession. A standardized nutrition care process consistent with the scientific method and a standardized language are two essential components required to articulate a conceptual model for clinical nutrition practice and documentation and distinguish clinical dietetics' unique body of knowledge. The conceptual model serves as an organizing framework to standardize and guide nutrition practitioners' clinical judgments or critical thinking processes and document information linking nutrition care to patient outcomes.

A Standardized Nutrition Care Process and Language Are Essential Components of a Conceptual Model to Guide and Document Nutrition Care and Patient Outcomes

Objective To compare documentation of two groups of clinical nutrition practitioners for evidence of the nutrition care process. Design This study used a comparative descriptive design. A retrospective chart review was conducted on all nutrition documentation in closed patient records. Documentation of two groups of nutrition practitioners (institution A=practitioners who received initial orientation and routine reinforcement in use of nutrition care process standards; institution B=practitioners who received orientation in use of a further assessment and medical nutrition therapy intervention procedure) was compared for evidence of a six-step nutrition care process. Sample/Setting The sample consisted of randomly selected patient records (N=60). A total of 15 oncology and 15 chronic renal failure patient records from each of two Midwestern tertiary-care hospitals were reviewed. Main Outcome Measures Outcome measures were number of nutrition care process steps documented, appropriate relationships among documented steps in the nutrition care process, and the number of complete, incomplete, and interrupted chains. Statistical Analyses Two-sample t tests and χ 2 analyses were used. Results Nutrition practitioners at institution A documented approximately three times as many nutrition care process steps per patient per chain that demonstrated appropriate relationships as did nutrition practitioners at institution B (2.69±1.15 and 0.80±0.62, respectively [mean±standard deviation]) ( P Conclusions Nutrition practitioners with orientation to nutrition care process standards documented more related nutrition care process steps than practitioners without this orientation. Providing nutrition practitioners with ongoing education and clinical experiences in use and documentation of the nutrition care process and a standardized language may be indicated to increase the number of completed nutrition care process chains and improve documentation of nutrition care and patient outcomes.

https://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1018&context=nutritionfacpub

Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners.

Nomenclature of Diseases and Operations and Manual of the Medical Record

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Nomenclature of Diseases and Operations and Manual of the Medical Record