Documentation of Nutrition Care

Documentation of Nutrition Care - The Medical Record and...

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Unformatted text preview: The Medical Record and Documentation of Nutrition Care Medical Record • • • Is a systematic documentation of a patient’s Is medical history and care medical Used both for the physical document and Used the body of information that comprises the person’s health history person’s Intensely personal documents; many issues Intensely around access, storage, and disposal around Parts of the Medical Record • • • • • • • Demographics/legal information Medical history Medical encounters Orders Progress notes Test results Other information Demographics • • • • • Non-medical information Identifying numbers, addresses, contact Identifying numbers numbers Information about race and religious Information preference, occupation preference, Health insurance information Emergency contacts Medical History • • • • Surgical history – chronicle of surgery performed Surgical on the patient; may include dates of surgery, operative reports, etc operative Obstetric history – lists prior pregnancies and their Obstetric outcomes; complications of pregnancy outcomes; Medication and medical allergies – summary of Medication the patient’s current and previous medications and allergies to medications allergies Family history – health status of immediate family Family members and causes of death; diseases common in the family; important for predicting risk of certain genetic or chronic diseases genetic Medical History • • Social history – chronicle of human Social interactions; important relationships, education, career and financial status, community and family support community Habits – that impact health, such as tobacco Habits use, alcohol intake, recreational drug use, activity, and diet; may address sexual habits and sexual preferences and Medical History • • • Immunization history – history of Immunization immunizations immunizations Growth chart and developmental history, Growth including comparison to other children of the same age and gender the Addresses developmental milestones such Addresses as walking, talking, etc. Medical Encounters • • • Summary of an episode of care Outpatient or inpatient admission Includes: • Chief complaint • History of the present illness • Physical exam • Assessment and plan Orders • • • Written orders by medical providers – Written physicians (residents or attendings) and nurse practitioners; others with order writing privileges writing Must be signed Can find diet orders, lab orders, Can medications, enteral and parenteral orders medications, Progress Notes • • • • Daily updates entered into the medical record Daily documenting clinical changes, new information, results of tests results May be in SOAP, narrative, or other formats Generally entered by all members of the health Generally care team (doctors, nurses, physical therapists, dietitians, pharmacists dietitians, Kept in chronological order Test Results • • Blood tests, Blood radiology exams, pathology, specialized testing specialized Often accessed Often online, even where there is a paper medical record medical Other information • • • Flow sheets that often summarize vital Flow signs, inputs and outputs, etc signs, Informed consent forms Radiologic images, EKG tracings, outputs Radiologic from medical devices from Nutritional Care Record • • • Written documentation of the nutritional Written care process, including the interventions and activities used to meet the nutritional objectives objectives “If it’s not documented, it didn’t happen.” Medical record is a legal document. Nutrition Care Documentation 1. 2. Quality assurance Communication 1. Health care team 2. Verifies care given 3. JCAHO accreditation 4. Peer review 5. State audits Medical Record Documentation • • • • All entries should be written in black pen or All typewritten typewritten Documentation should be complete, clear, Documentation concise, objective, legible, and accurate concise, Entries should include the date, time, and Entries service service Complete sentences are not necessary, but Complete grammar and spelling should be correct grammar Medical Record Documentation • • • Abbreviations that are unclear or which Abbreviations have multiple meanings should be avoided have Most institutions have an approved list of Most allowed abbreviations allowed JCAHO has a list of forbidden JCAHO abbreviations which have been associated with medical errors in the past with Medical Record Documentation • • • Personal opinions, comments critical or casting Personal doubt on other team members (e.g. “chart wars”) should be avoided should Documentation should be done at the time the Documentation service or procedure is performed; it should never be done in advance be All entries should be signed at the end and include All credentials. In some institutions, chart notes will include pager numbers or PIN numbers include Medical Record Documentation • • • No one should ever chart or sign the medical No record for someone else record Late entries should be identified as such, including Late the actual date and time of the entry and the date and time it should have been documented and When making corrections, do not obliterate the When original entry. Draw a single line through it, note “error” and correct it, listing the date and time of the correction and your initials the Verbal/Telephone Orders • • • Verbal/Telephone orders: orders dictated over the Verbal/Telephone phone or in person to a person qualified to receive them; these are then documented in the medical record and implemented prior to physician signature signature Most institutions require that verbal/telephone orders be signed by the physician or provider within 24 hours within Verbal/telephone orders should never be accepted Verbal/telephone from a provider who is physically present and able to write the order him/herself to Order Writing Privileges • • • This allows non-physician licensed professionals This to write orders within a given scope of practice which are implemented without physician cowhich signature signature For nutrition professionals, this might include For changes in diet orders, ordering of lab tests pertinent to nutrition care, and making changes in parenteral or enteral regimens parenteral Sometimes order writing privileges are delegated Sometimes in the context of a protocol, which clearly defines indications and interventions indications Verbal Orders and Order Writing Privileges • • Dietitian acceptance of verbal/phone orders Dietitian from providers and use of order writing privileges may be dictated by state law and/or institutional policy (generally medical staff bylaws) medical Acceptance of verbal/phone orders may be Acceptance limited by institutional policy to orders pertaining to nutritional care pertaining Documentation Styles • • • • • • • • • • ADIME (assessment, diagnosis, intervention, ADIME monitoring and evaluation) monitoring DAP (diagnosis, assessment, plan) DAR (data, action, response) PIE (problem, intervention, evaluation) PES (problem, etiology, symptoms) IER (intervention, evaluation, revision) HOAP (history, observation, assessment, plan) SAP (screen, assess, plan) SOAPIER (subjective, objective, SOAPIER analysis/assessment, plan, intervention, evaluation, revisions) revisions) SOAP (subjective, objective, assessment, plan) SOAP Notes S: Subjective • Info provided by patient, family, or other • Pertinent socioeconomic, cultural info • Level of physical activity Level • Significant nutritional history: usual eating Significant pattern, cooking, dining out pattern, • Work schedule SOAP Notes—cont’d O: Objective • Factual, reproducible observations • Diagnosis • Height, age, weight—and weight gain/loss Height, patterns patterns • Lab data • Clinical data (nausea, diarrhea) • Diet order • Medications • Estimation of nutritional needs SOAP Notes—cont’d A: Assessment • Nutrition diagnosis • Interpretation of patient’s status based on Interpretation subjective and objective info subjective • Evaluation of nutritional history • Assessment of laboratory data and Assessment medications medications • Assessment of diet order • Assessment of patient’s comprehension and Assessment motivation motivation SOAP Notes—cont’d P: Plan • Diagnostic studies needed • Further workup, data needed • Medical nutrition therapy goals • Education plans • Recommendations for nutritional care SOAP EXAMPLE • • • • S: Patient works night shift, eats two meals a day, S: before and after his shift; fried foods, burgers, ice cream, beers in restaurants. Does not add salt to foods. Activity: Plays golf 1x month. Activity: O: 34 y.o. male s/p MI with history of htn, DM2, O: hyperlipidemia. • Ht: 5 ft. 10 in; wt: 250 lb; BMI 36, Obesity II A: Excessive sodium intake (NI-5.10.2) related to A: frequent use of vending foods as evidenced by diet history. Pt could benefit from increased activity and gradual wt loss as recovery allows gradual P: Provided basic education (E-1) on 3-4 gram sodium P: diet and wt management guidelines diet • Patient will return to outpatient nutrition clinic for Patient lifestyle intervention and counseling (C-2.1). Pros and Cons of SOAP Charting PROS • Common use by nutrition Common care professionals and other disciplines other • Taught in most dietetics Taught education programs education • Easy to learn and utilize CONS • Tends to encourage Tends lengthy chart notes lengthy • One study suggests One physicians are less likely to respond to this format than others* than • Downplays evaluation • Emphasizes legitimacy of Emphasizes objective over subjective data data *Skipper A, Young M, Rotman N, Nagl H. Physicians’ implementation of dietitians’ recommendations: a study of the effectiveness of dietitians. J Am Diet Assoc 1994;94:45-49. ADIME Developed to facilitate the NCP • A – Assessment • D – Diagnosis • I – Intervention • M – Monitoring • E - Evaluation Assessment (A) • • All data pertinent to clinical decision All making, including diet history, medical history, medications, physical assessment, lab values, current diet order, estimated nutritional needs nutritional Should include relevant data only Diagnosis • • Should include PES statement for nutrition Should diagnosis diagnosis Patients may have more than one diagnosis, Patients but try to choose the one or two most pertinent, or the ones you mean to address pertinent, Intervention • What do you recommend or plan to do to What address the nutrition diagnoses? address • Recommend change in food-nutrient Recommend delivery (supplement, change in diet, nutrition support, vitamin-mineral supplement) (NI) supplement) • Nutrition education (E) • Nutrition counseling (C) • Coordination of nutrition care (RC) Monitoring and Evaluation (ME) • • What will you monitor to determine if the What nutrition intervention was successful? nutrition Generally based on the signs and symptoms • Weight • Intake • Lab values • Clinical symptoms Example of ADIME • • A - 34 y.o. male s/p MI with history of htn, DM2, 34 hyperlipidemia; ht: 5 ft. 10 in; wt: 250 lb; BMI 36, obesity II. Patient works night shift, eats two meals a day, before and after his shift--fried foods, burgers, ice cream, beers in restaurants.. Does not add salt to foods. Activity: Plays golf 1x month. add D - Excessive energy intake (NI-1.5); excessive Excessive sodium intake (NI-5.10.2) related to frequent use of restaurant foods as evidenced by diet history. Example of ADIME • • I – Provided basic education (E-1) on 3-4 gram Provided sodium diet and wt. management guidelines (nutrition education); pt to return to outpatient nutrition clinic for lifestyle intervention (C-2.1) nutrition ME – Evaluate weight (S-1.1.4), blood pressure ME (S-3.1.7), diet history at outpatient visit sodium intake (FI-6.2); energy intake (FI1.1.1); fat intake (FI-5.1.1) Re-check lipids in 3 months (S-2.6) (FI-5.1.1) Narrative Note • • • Brief summary of progress, data, action in a Brief paragraph format paragraph Frequently used to document brief Frequently interventions or follow-ups to initial assessments assessments Nutrition professionals may use for same Nutrition purpose or to document food preference interviews, response to a patient question or complaint, re-screening of low risk pts complaint, Brief Narrative Note Example 34 y.o. male s/p MI with history of htn, DM2, 34 hyperlipidemia. Ht: 5 ft. 10 in; wt: 250 lb Patient works night shift, eats two meals a day, before and after his shift, fried foods, burgers, ice cream, beers in restaurants. Does not add salt to foods. Nutrition diagnosis: Excessive energy intake (NI-1.5) related to high intake of fat and restaurant foods aeb BMI and diet history. Response (Evaluation) Pt was able to list high sodium foods and appropriate diet changes (BEsodium 2.2.1) 2.2.1) Electronic Medical Record • • • • Many health care institutions are Many implementing electronic medical records (Aultman and Mercy Medical Center) All disciplines can access the patient chart All concurrently concurrently Entries are more legible, making errors less Entries likely likely Data can be organized to support clinical Data decision making decision Charting Format Case Study • • • • • • • • • MJ is a 75 y.o. African-American female with PMH of MJ HTN and DM admitted with cellulitis of right foot. She is retired and active in her church. She does not get around much due to arthritis in her knees. Follows no special diet at home; eats breakfast at Bob Evans daily; biscuits and sausage gravy, eggs, and grits. “The doctor said I had a little sugar; I don’t eat much The bakery.” Does not test glucose at home Ht: 5 ft. 3 in; weight 184 lb. BMI 32.6; Ht: Meds: Toprol 20 mg b.i.d.; no meds for diabetes at present Labs: TC: 250; LDL-C: 180 mg/dl; A1C: 9%; Labs: ECR at current weight: 2000 kcals; ECR Provided survival skills information regarding nutrition Provided therapy for diabetes; referred to diabetes self management program program Consulted diabetes educator to obtain home monitor. Consulted Charting Format Issues • • Nutrition care documentation is unique in Nutrition that it is often consultative, intended to elicit action (orders) on the part of the provider provider There is little data to demonstrate the There efficacy of one chart format over another in conveying recommendations to physicians, communicating with other team members, and meeting legal and regulatory requirements requirements Chart Formats and Computerized Medical Records (CMRs) • • • • Charting formats will likely dwindle in importance Charting as computerized medical records become more common common Well-designed CMRs allow clinicians to easily Well-designed access and organize the information they need without repetition without Most CMRs are designed around the needs of Most physicians and nurses physicians Nutrition care professionals should be assertive in Nutrition shaping the final product to meet their needs shaping Mercy Medical Center Meditech Charting: Nutrition Assessment Mercy Medical Center Initial Assessment (cont) Mercy Medical Center Initial Assessment (cont) Mercy Medical Center Meditech Charting: Nutrition Assessment Mercy Medical Center Meditech Charting Reassessment Mercy Medical Center Meditech Charting Reassessment Aultman Hospital Nutrition Progress Notes Aultman Hospital Nutrition Progress Notes ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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