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Nutrition Therapy and Pathophysiology | 3eNelms | Sucher | Lacey | Roth

R. Gerald Nelms, PhDWright State University

Documentation of the Nutrition Care Process

Chapter 6

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Charting: Documentation of the Nutrition Care Process

• Documentation in the medical record– Systematic recording of patients’ care– Ongoing conversation– Clear and comprehensive record– Continuous quality improvement– Current procedural terminology (CPT) codes– Use of terminology consistent with prospective

payment system– Legal documentation

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Purposes of Medical Record Charting

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Electronic Medical Records

• Application environment• Supports patient’s medical record across

inpatient and outpatient settings• Advantages

– Expedited transcription and delivery of physician orders, reduction of errors, improvement in patient safety, and facilitation of achieving positive patient outcomes

• Disadvantage– Inconsistencies across systems

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An EMR Template

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Documentation of the Nutrition Care Process

• Standardized language and medical abbreviations– JCAHO: see abbreviations not to use (Table

6.2)– Use nutrition diagnostic terminology

• POMR – problem-oriented medical record– Data, problem list, care plan, progress notes,

and discharge summary

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The Joint Commission Official “Do Not Use” List

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Organization of Nutrition Documentation

• SOAP – Subjective data – Objective data – Assessment– Plan

• PES: problem, etiology, and signs/symptoms – Documentation of the nutrition diagnosis

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ADIM and IER

• Assessment, diagnosis, intervention, and monitoring/evaluation (ADIM)– Reflects nutrition care process– D section includes PES statements

• IER notes – Simplified SOAP– Intervention, evaluation, and revision of care

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Focus, PIE, and CBE

• Focus notes– Blending of SOAP and IER formats

• PIE notes– Problem, intervention, and evaluation

• Charting by exception (CBE)– Recording only unusual or out-of-the ordinary

events

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Keeping a Personal Medical Notebook

• Create your own system of keeping notes for brainstorming problems and expressing own responses

• Follow a standard format or invent your own

• Keep it confidential

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Guidelines for All Charting

• Chart what you see as significant• Sign with full name and status • Be timely• Do you own charting; never chart for

anyone else• Do not chart procedure until it is

completed• Remember: charts are legal as well as

medical documents

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Charting Guidelines: Style/Formatting

• If charting by hand, use black ink• Write clearly so the meaning of your note

is clear• Avoid abbreviations unless you are certain

they will be immediately understandable• If handwriting, begin your note

immediately after the previous note; do not leave white space

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Charting Guidelines: Content

• Include too much detail rather than too little

• When writing objective notes, do not assume or infer

• Set aside biases• Use neutral language• Use “patient” or “client” rather than name

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Charting Guidelines: Protocols

• Always keep record intact• Cross out mistakes with single horizontal

line; write word “error” above it• Sign notes after printing name

(electronically or by hand)• Include date and time• Follow agency’s or institution’s guidelines

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Confidentiality

• In U.S., Health Insurance Portability and Accountability Act of 1996 (HIPAA)– Protects information about clients that is

gathered by examination, observation, conversation, or treatment

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Beyond Charting: Functions

• Record information• Inform• Persuade• Entertain

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Beyond Charting: Rhetorical Norms

• Rhetorical norms– Subject matter– Purpose – Audience– Ethos

• Levels of discourse

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Beyond Charting: The Writing and Reporting Process

• Steps in the writing process– Prewriting or invention– Drafting– Revision– Editing

• Report your own research

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Conclusions: Your Ethos- Establishing Expertise

• Follow code of ethics: your professional obligation is to convey accurate information for all audiences

• Take continued professional education• Draw on ongoing knowledge