Presentation on theme: "The Medical Record and Documentation of Nutrition Care"— Presentation transcript:
1 The Medical Record and Documentation of Nutrition Care
2 Medical RecordIs a systematic documentation of a patient’s medical history and careUsed both for the physical document and the body of information that comprises the person’s health historyIntensely personal documents; many issues around access, storage, and disposal
3 Parts of the Medical Record Demographics/legal informationMedical historyMedical encountersOrdersProgress notesTest resultsOther information
4 Demographics Non-medical information Identifying numbers, addresses, contact numbersInformation about race and religious preference, occupationHealth insurance informationEmergency contacts
5 Medical HistorySurgical history – chronicle of surgery performed on the patient; may include dates of surgery, operative reports, etcObstetric history – lists prior pregnancies and their outcomes; complications of pregnancyMedication and medical allergies – summary of the patient’s current and previous medications and allergies to medicationsFamily 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
6 Medical HistorySocial history – chronicle of human interactions; important relationships, education, career and financial status, community and family supportHabits – that impact health, such as tobacco use, alcohol intake, recreational drug use, activity, and diet; may address sexual habits and sexual preferences
7 Medical History Immunization history – history of immunizations Growth chart and developmental history, including comparison to other children of the same age and genderAddresses developmental milestones such as walking, talking, etc.
8 Medical Encounters Summary of an episode of care Outpatient or inpatient admissionIncludes:Chief complaintHistory of the present illnessPhysical examAssessment and plan
9 OrdersWritten orders by medical providers – physicians (residents or attendings) and nurse practitioners; others with order writing privilegesMust be signedCan find diet orders, lab orders, medications, enteral and parenteral orders
11 Progress NotesDaily updates entered into the medical record documenting clinical changes, new information, results of testsMay be in SOAP, narrative, or other formatsGenerally entered by all members of the health care team (doctors, nurses, physical therapists, dietitians, pharmacistsKept in chronological order
13 Test ResultsBlood tests, radiology exams, pathology, specialized testingOften accessed online, even where there is a paper medical record
14 Other informationFlow sheets that often summarize vital signs, inputs and outputs, etcInformed consent formsRadiologic images, EKG tracings, outputs from medical devices
15 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.
16 Nutrition Care Documentation Quality assuranceCommunicationHealth care teamVerifies care givenJCAHO accreditationPeer reviewState audits
17 Medical Record Documentation All entries should be written in black pen or typewrittenDocumentation should be complete, clear, concise, objective, legible, and accurateEntries should include the date, time, and serviceComplete sentences are not necessary, but grammar and spelling should be correct
18 Medical Record Documentation Abbreviations that are unclear or which have multiple meanings should be avoidedMost institutions have an approved list of allowed abbreviationsJCAHO has a list of forbidden abbreviations which have been associated with medical errors in the past
19 Medical Record Documentation Personal opinions, comments critical or casting doubt on other team members (e.g. “chart wars”) should be avoidedDocumentation should be done at the time the service or procedure is performed; it should never be done in advanceAll entries should be signed at the end and include credentials. In some institutions, chart notes will include pager numbers or PIN numbers
20 Medical Record Documentation No one should ever chart or sign the medical record for someone elseLate entries should be identified as such, including the actual date and time of the entry and the date and time it should have been documentedWhen 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
21 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 signatureMost institutions require that verbal/telephone orders be signed by the physician or provider within 24 hoursVerbal/telephone orders should never be accepted from a provider who is physically present and able to write the order him/herself
22 Order Writing Privileges This allows non-physician licensed professionals to write orders within a given scope of practice which are implemented without physician co-signatureFor nutrition professionals, this might include changes in diet orders, ordering of lab tests pertinent to nutrition care, and making changes in parenteral or enteral regimensSometimes order writing privileges are delegated in the context of a protocol, which clearly defines indications and interventions
23 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
25 SOAP Notes S: Subjective Info provided by patient, family, or other Pertinent socioeconomic, cultural infoLevel of physical activitySignificant nutritional history: usual eating pattern, cooking, dining outWork schedule
27 SOAP Notes—cont’d A: Assessment Nutrition diagnosis Interpretation of patient’s status based on subjective and objective infoEvaluation of nutritional historyAssessment of laboratory data and medicationsAssessment of diet orderAssessment of patient’s comprehension and motivation
28 SOAP Notes—cont’d P: Plan Diagnostic studies needed Further workup, data neededMedical nutrition therapy goalsEducation plansRecommendations for nutritional care
29 SOAP EXAMPLES: 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 IIA: Excessive sodium intake (NI ) related to frequent use of vending foods as evidenced by diet history. Pt could benefit from increased activity and gradual wt loss as recovery allowsP: Provided basic education (E-1) on 3-4 gram sodium diet and wt management guidelinesPatient will return to outpatient nutrition clinic for lifestyle intervention and counseling (C-2.1).
30 Pros and Cons of SOAP Charting Common use by nutrition care professionals and other disciplinesTaught in most dietetics education programsEasy to learn and utilizeCONSTends to encourage lengthy chart notesOne study suggests physicians are less likely to respond to this format than others*Downplays evaluationEmphasizes 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.
31 ADIME Developed to facilitate the NCP A – Assessment D – Diagnosis I – InterventionM – MonitoringE - Evaluation
32 Assessment (A)All data pertinent to clinical decision making, including diet history, medical history, medications, physical assessment, lab values, current diet order, estimated nutritional needsShould include relevant data only
33 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
34 InterventionWhat 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)
35 Monitoring and Evaluation (ME) What will you monitor to determine if the nutrition intervention was successful?Generally based on the signs and symptomsWeightIntakeLab valuesClinical symptoms
36 Example of ADIMEA - 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 ) related to frequent use of restaurant foods as evidenced by diet history.
37 Example of ADIMEI – 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)
38 Narrative NoteBrief summary of progress, data, action in a paragraph formatFrequently used to document brief interventions or follow-ups to initial assessmentsNutrition 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
39 Brief Narrative Note Example 34 y.o. male s/p MI with history of htn, DM2, hyperlipidemia. Ht: 5 ft. 10 in; wt: 250 lbPatient 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 (BE-2.2.1)
40 Electronic Medical Record Many health care institutions are implementing electronic medical records (Aultman and Mercy Medical Center)All disciplines can access the patient chart concurrentlyEntries are more legible, making errors less likelyData can be organized to support clinical decision making
41 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 homeHt: 5 ft. 3 in; weight 184 lb. BMI 32.6;Meds: Toprol 20 mg b.i.d.; no meds for diabetes at presentLabs: 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 programConsulted diabetes educator to obtain home monitor.
42 Charting Format Issues Nutrition care documentation is unique in that it is often consultative, intended to elicit action (orders) on the part of the providerThere 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
43 Chart Formats and Computerized Medical Records (CMRs) Charting formats will likely dwindle in importance as computerized medical records become more commonWell-designed CMRs allow clinicians to easily access and organize the information they need without repetitionMost CMRs are designed around the needs of physicians and nursesNutrition care professionals should be assertive in shaping the final product to meet their needs
44 Mercy Medical Center Meditech Charting: Nutrition Assessment