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.
J Hum Nutr Diet
; 37(2): 593-600, 2024 Apr.
Article
em En
| MEDLINE
| ID: mdl-38268332
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.Palavras-chave
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Dietética
/
Nutricionistas
/
Distúrbios Nutricionais
Tipo de estudo:
Guideline
Limite:
Humans
País/Região como assunto:
Europa
Idioma:
En
Revista:
J Hum Nutr Diet
Assunto da revista:
CIENCIAS DA NUTRICAO
Ano de publicação:
2024
Tipo de documento:
Article
País de afiliação:
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