Transcript The Medical Record and Documentation of Nutrition Care

The Medical Record and
Documentation of Nutrition Care
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
Parts of the Medical Record
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Demographics/legal information
Medical history
Medical encounters
Orders
Progress notes
Test results
Other information
Demographics
• Non-medical information
• Identifying numbers, addresses, contact
numbers
• Information about race and religious
preference, occupation
• Health insurance information
• Emergency contacts
Medical History
• Surgical history – chronicle of surgery performed
on the patient; may include dates of surgery,
operative reports, etc
• Obstetric history – lists prior pregnancies and their
outcomes; complications of pregnancy
• Medication and medical allergies – summary of
the patient’s current and previous medications and
allergies to medications
• Family history – health status of immediate family
members and causes of death; diseases common in
the family; important for predicting risk of certain
genetic or chronic diseases
Medical History
• Social history – chronicle of human
interactions; important relationships,
education, career and financial status,
community and family support
• Habits – that impact health, such as tobacco
use, alcohol intake, recreational drug use,
activity, and diet; may address sexual habits
and sexual preferences
Medical History
• Immunization history – history of
immunizations
• Growth chart and developmental history,
including comparison to other children of
the same age and gender
• Addresses developmental milestones such
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 –
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
Test Results
• Blood tests,
radiology exams,
pathology,
specialized testing
• Often accessed
online, even where
there is a paper
medical record
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.
Nutrition Care Documentation
1. Quality assurance
2. 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
typewritten
• Documentation should be complete, clear,
concise, objective, legible, and accurate
• Entries should include the date, time, and
service
• Complete sentences are not necessary, but
grammar and spelling should be correct
Medical Record Documentation
• Abbreviations that are unclear or which
have multiple meanings should be avoided
• Most institutions have an approved list of
allowed abbreviations
• JCAHO has a list of forbidden
abbreviations which have been associated
with medical errors in the past
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
Medical Record Documentation
• No one should ever chart or sign the medical
record for someone else
• Late entries should be identified as such, including
the actual date and time of the entry and the date
and time it should have been documented
• When making corrections, do not obliterate the
original entry. Draw a single line through it, note
“error” and correct it, listing the date and time of
the correction and your initials
Verbal/Telephone Orders
• Verbal/Telephone orders: orders dictated over the
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
• Most institutions require that verbal/telephone
orders be signed by the physician or provider
within 24 hours
• Verbal/telephone orders should never be accepted
from a provider who is physically present and able
to write the order him/herself
Order Writing Privileges
• This allows non-physician licensed professionals
to write orders within a given scope of practice
which are implemented without physician cosignature
• For nutrition professionals, this might include
changes in diet orders, ordering of lab tests
pertinent to nutrition care, and making changes in
parenteral or enteral regimens
• Sometimes order writing privileges are delegated
in the context of a protocol, which clearly defines
indications and interventions
Verbal Orders and Order Writing
Privileges
• Dietitian acceptance of verbal/phone orders
from providers and use of order writing
privileges may be dictated by state law
and/or institutional policy (generally
medical staff bylaws)
• Acceptance of verbal/phone orders may be
limited by institutional policy to orders
pertaining to nutritional care
Documentation Styles
• ADIME (assessment, diagnosis, intervention,
monitoring 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.
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
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
(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)
Narrative Note
• Brief summary of progress, data, action in
a paragraph format
• Frequently used to document brief
interventions or follow-ups to initial
assessments
• Nutrition professionals may use for same
purpose or to document food preference
interviews, response to a patient question or
complaint, re-screening of low risk pts
Brief Narrative Note Example
34 y.o. male s/p MI with history of htn, DM2,
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 (BE2.2.1)
Electronic Medical Record
• Many health care institutions are
implementing electronic medical records
(Aultman and Mercy Medical Center)
• All disciplines can access the patient chart
concurrently
• Entries are more legible, making errors less
likely
• Data can be organized to support clinical
decision making
Charting Format Case Study
• MJ is a 75 y.o. African-American female with PMH of
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
bakery.”
• Does not test glucose at home
• Ht: 5 ft. 3 in; weight 184 lb. BMI 32.6;
• Meds: Toprol 20 mg b.i.d.; no meds for diabetes at present
• Labs: TC: 250; LDL-C: 180 mg/dl; A1C: 9%;
• ECR at current weight: 2000 kcals;
• Provided survival skills information regarding nutrition
therapy for diabetes; referred to diabetes self management
program
• Consulted diabetes educator to obtain home monitor.
Charting Format Issues
• Nutrition care documentation is unique in
that it is often consultative, intended to
elicit action (orders) on the part of the
provider
• There is little data to demonstrate the
efficacy of one chart format over another in
conveying recommendations to physicians,
communicating with other team members,
and meeting legal and regulatory
requirements
Chart Formats and Computerized
Medical Records (CMRs)
• Charting formats will likely dwindle in importance
as computerized medical records become more
common
• Well-designed CMRs allow clinicians to easily
access and organize the information they need
without repetition
• Most CMRs are designed around the needs of
physicians and nurses
• Nutrition care professionals should be assertive in
shaping the final product to meet their needs
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