Evaluation of the nutrition care process documentation in the patients' records using the Diet-NCP-Audit: experience in a medium-sized multi-site Swiss hospital.

ABSTRACT

BACKGROUND: The nutrition care process (NCP) is a four-step systematic approach to guide dietitians in providing high-quality nutrition care. It fosters critical thinking and enhances the consistency of dietitians' documentation. Following international recommendations, University Training Hospital of Fribourg (HFR) implemented it in 2013. This study aimed to evaluate the quality of NCP documentation in electronic patient records (EPRs) and to determine the nutrition problems dietitians most often identified while documenting their actions. METHODS: The audit was performed on 92 EPRs using the Diet-NCP-Audit, which was translated into French for this study. RESULTS: The documentation quality was assessed as high in 62% of the EPRs, and nutrition diagnoses were mostly documented. In half of the EPRs, nutrition assessment (step 1 of the NCP) was inconsistent with nutrition diagnosis (step 2). Dietitians often used the same nutrition problems out of the 73 nutrition problems defined in NCP terminology, only 4 (5%) represented 58% of the 189 problems identified in the EPR audit. CONCLUSION: EPRs were mostly assessed as high quality. However, the entire process requires improved consistency. The poorly documented link between the NCP steps and the restricted choices of nutrition problems dietitians identified should be addressed because they could reveal that dietitians have not fully adopted critical thinking, which the NCP stresses.