RESUMO
Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals-nurses, physicians, advanced practice providers, pharmacists, and dietitians-identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization's Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.
Assuntos
Documentação/métodos , Registros Eletrônicos de Saúde/normas , Desnutrição/terapia , Terapia Nutricional/métodos , Consenso , Humanos , Avaliação Nutricional , Estado Nutricional , Médicos , Sociedades MédicasRESUMO
Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals-nurses, physicians, advanced practice providers, pharmacists, and dietitians-identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization's Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.
Assuntos
Registros Eletrônicos de Saúde/normas , Terapia Nutricional , Consenso , Humanos , Comunicação Interdisciplinar , Desnutrição/diagnóstico , Desnutrição/terapia , Programas de Rastreamento , Avaliação Nutricional , Equipe de Assistência ao Paciente , Alta do Paciente , Pacientes , Software , Estados UnidosRESUMO
When hospitals embark on bundled payment programs, they should take steps to ensure physicians are on board. Key steps include: Contacting physicians while in the planning stages so they can prepare to participate in the new model. Establishing resources and processes designed to make compliance easier. Educating physicians about the importance of coding and documentation.