Transcript Document

Charting/NCP
Charting a Patient is Entering
Information Into Their Medical
Record
 Is a systematic documentation of a patient’s medical history
and care
 Used both for the physical document and the body of
information that comprises the person’s health history
 Intensely personal documents; many issues around access,
storage, and disposal (HIPAA)
Parts of the Medical Record
 Demographics/legal information
 Medical history
 Medical encounters
 Test results
 Orders
 Progress notes
 Other information
Orders
 Written orders by medical providers – physicians (residents
or attendings) and nurse practitioners; others with order
writing privileges
 Must be signed
 Can find diet orders, lab orders, medications, enteral and
parenteral orders
Progress Notes
 Daily updates entered into the medical record
documenting clinical changes, new information, results
of tests
 May be in SOAP, narrative, or other formats
 Generally entered by all members of the health care
team (doctors, nurses, physical therapists, dietitians,
pharmacists
 Kept in chronological order
Other information
 Flow sheets that often summarize vital signs, inputs and
outputs, etc
 Informed consent forms
 Radiologic images, EKG tracings, outputs from medical
devices
Nutritional Care Record
 Written documentation of the nutritional care process,
including the interventions and activities used to meet the
nutritional objectives
 “If it’s not documented, it didn’t happen.”
 Medical record is a legal document.
Why is Nutrition Care
Documentation Important?
1.
2.
Quality assurance
Communication
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5.
Health care team
Verifies care given
JCAHO accreditation
Peer review
State audits
What do I include in the
Medical Record Documentation?
 Personal opinions, comments critical or casting doubt on
other team members (e.g. “chart wars”) should be
avoided
 Documentation should be done at the time the service or
procedure is performed; it should never be done in
advance
 All entries should be signed at the end and include
credentials. In some institutions, chart notes will include
pager numbers or PIN numbers
Documentation Styles
 ADIME (assessment, diagnosis, intervention, monitoring
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and evaluation)
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, analysis/assessment,
plan, intervention, evaluation, 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
 Significant nutritional history: usual eating pattern,
cooking, dining out
 Work schedule
SOAP Notes—cont’d
O: Objective
 Factual, reproducible observations
 Diagnosis
 Height, age, weight—and weight gain/loss 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 subjective
and objective info
 Evaluation of nutritional history
 Assessment of laboratory data and medications
 Assessment of diet order
 Assessment of patient’s comprehension and
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, before and
after his shift; fried foods, burgers, ice cream, beers in
restaurants. Does not add salt to foods. Activity: Plays golf 1x
month.
 O: 34 y.o. male s/p MI with history of htn, DM2,
hyperlipidemia.
 Ht: 5 ft. 10 in; wt: 250 lb; BMI 36, Obesity II
 A: Excessive sodium intake (NI-5.10.2) related to frequent use
of vending foods as evidenced by diet history. Pt could benefit
from increased activity and gradual wt loss as recovery allows
 P: Provided basic education (E-1) on 3-4 gram sodium diet and
wt management guidelines
 Patient will return to outpatient nutrition clinic for lifestyle
intervention and counseling (C-2.1).
Pros and Cons of SOAP Charting
PROS
 Common use by nutrition
care professionals and other
disciplines
 Taught in most dietetics
education programs
 Easy to learn and utilize
CONS
 Tends to encourage lengthy
chart notes
 One study suggests physicians
are less likely to respond to
this format than others*
 Downplays evaluation
 Emphasizes legitimacy of
objective over subjective 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.
Let’s Talk About the NCP
ADIME
Developed to facilitate the NCP
 A – Assessment
 D – Diagnosis
 I – Intervention
 M – Monitoring
 E - Evaluation
Assessment (A)
 All data pertinent to clinical decision making, including diet
history, medical history, medications, physical assessment, lab
values, current diet order, estimated nutritional needs
 Should include relevant data only
Diagnosis
 Should include PES statement for nutrition diagnosis
 Patients may have more than one diagnosis, but try to choose
the one or two most pertinent, or the ones you mean to
address
Nutrition diagnosis step is
articulated in PES Statement
 PES Statement =
 Problem…
 related to…Etiology…
o as evidenced by…Signs or symptoms
Evaluating your PES statement
 There are no “right” or “wrong” PES statements
 But ….
 Some are better than others!!
 Questions have been developed for you to use when
evaluating your PES statement
Evaluating your PES statement
 P
 Can the RD resolve or improve the nutrition diagnosis ?
 Consider the intake domain as the preferred problem
 E
 Is the etiology the “root” cause?
 Will intervention resolve the problem by addressing the etiology?
 Can RD intervention at least lessen the signs and symptoms?
 S
 Will measuring the s/s indicate if resolved or improved?
 Are the signs and symptoms specific enough?
 PES Overall
 Does nutrition assessment data support the nutrition diagnosis,
etiology, and signs and symptoms?
Intervention
 What do you recommend or plan to do to address the
nutrition diagnoses?
 Recommend change in food-nutrient delivery (supplement,
change in diet, nutrition support, vitamin-mineral supplement)
(NI)
 Nutrition education (E)
 Nutrition counseling (C)
 Coordination of nutrition care (RC)
Monitoring and Evaluation (ME)
 What will you monitor to determine if the nutrition
intervention was successful?
 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,
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.
 D - Excessive energy intake (NI-1.5); 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 sodium
diet and wt. management guidelines (nutrition
education); pt to return to outpatient nutrition clinic for
lifestyle intervention (C-2.1)
 ME – Evaluate weight (S-1.1.4), blood pressure (S3.1.7), diet history at outpatient visit sodium intake (FI6.2); energy intake (FI1.1.1); fat intake (FI-5.1.1) Recheck lipids in 3 months (S-2.6)
Questions?