The Medical Record and Documentation of Nutrition Care

1. The Medical Record and Documentation of Nutrition Care

2. Medical Record • Is a systematic documentation of a patient’s medical history and care • Used both for the physical document and the body of information that comprises the person’s health history • Intensely personal documents; many issues around access, storage, and disposal

3. Parts of the Medical Record • Demographics/legal information • Medical history • Medical encounters • Orders • Progress notes • Test results • Other information

4. Demographics • Non-medical information • Identifying numbers, addresses, contact numbers • Information about race and religious preference, occupation • Health insurance information • Emergency contacts

5. Medical History • Surgical history – chronicle of surgery performed on the patient; may include dates of surgery, operative reports, etc • Obstetric history – lists prior pregnancies and their outcomes; complications of pregnancy • Medication and medical allergies – summary of the patient’s current and previous medications and allergies to medications • Family 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 History • Social history – chronicle of human interactions; important relationships, education, career and financial status, community and family support • Habits – 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 gender • Addresses developmental milestones such as walking, talking, etc.

8. Medical Encounters • Summary of an episode of care • Outpatient or inpatient admission • Includes: • Chief complaint • History of the present illness • Physical exam • Assessment and plan

9. Orders • Written orders by medical providers – physicians (residents or attendings) and nurse practitioners; others with order writing privileges • Must be signed • Can find diet orders, lab orders, medications, enteral and parenteral orders

11. Progress Notes • Daily updates entered into the medical record documenting clinical changes, new information, results of tests • May be in SOAP, narrative, or other formats • Generally entered by all members of the health care team (doctors, nurses, physical therapists, dietitians, pharmacists • Kept in chronological order

13. Test Results • Blood tests, radiology exams, pathology, specialized testing • Often accessed online, even where there is a paper medical record

14. Other information • Flow sheets that often summarize vital signs, inputs and outputs, etc • Informed consent forms • Radiologic 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 assurance • Communication • Health care team • Verifies care given • JCAHO accreditation • Peer review • State audits

17. Medical Record Documentation • All entries should be written in black pen or typewritten • Documentation should be complete, clear, concise, objective, legible, and accurate • Entries should include the date, time, and service • Complete 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 avoided • Most institutions have an approved list of allowed abbreviations • JCAHO 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 avoided • Documentation should be done at the time the service or procedure is performed; it should never be done in advance • All 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 else • Late entries should be identified as such, including the actual date and time of the entry and the date and time it should have been documented • When 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 signature • Most institutions require that verbal/telephone orders be signed by the physician or provider within 24 hours • Verbal/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-signature • For nutrition professionals, this might include changes in diet orders, ordering of lab tests pertinent to nutrition care, and making changes in parenteral or enteral regimens • Sometimes 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

24. Documentation Styles • ADIME (assessment, diagnosis, intervention, monitoring and evaluation) • DAP (diagnosis, assessment, plan) • DAR (data, action, response) • PIE (problem, intervention, evaluation) • PES (problem, etiology, symptoms) • IER (intervention, evaluation, revision) • HOAP (history, observation, assessment, plan) • SAP (screen, assess, plan) • SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions) • SOAP (subjective, objective, assessment, plan)

25. SOAP Notes S: Subjective • Info provided by patient, family, or other • Pertinent socioeconomic, cultural info • Level of physical activity • Significant nutritional history: usual eating pattern, cooking, dining out • Work schedule

26. SOAP Notes—cont’d O: Objective • Factual, reproducible observations • Diagnosis • Height, age, weight—and weight gain/loss patterns • Lab data • Clinical data (nausea, diarrhea) • Diet order • Medications • Estimation of nutritional needs

27. SOAP Notes—cont’d A: Assessment • Nutrition diagnosis • Interpretation of patient’s status based on subjective and objective info • Evaluation of nutritional history • Assessment of laboratory data and medications • Assessment of diet order • Assessment of patient’s comprehension and motivation

28. SOAP Notes—cont’d P: Plan • Diagnostic studies needed • Further workup, data needed • Medical nutrition therapy goals • Education plans • Recommendations for nutritional care

29. SOAP EXAMPLE • S: 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 II • A: Excessive sodium intake (NI-5.10.2) related to frequent use of vending foods as evidenced by diet history. Pt could benefit from increased activity and gradual wt loss as recovery allows • P: Provided basic education (E-1) on 3-4 gram sodium diet and wt management guidelines • Patient will return to outpatient nutrition clinic for lifestyle intervention and counseling (C-2.1).

30. PROS Common use by nutrition care professionals and other disciplines Taught in most dietetics education programs Easy to learn and utilize CONS Tends to encourage lengthy chart notes One study suggests physicians are less likely to respond to this format than others* Downplays evaluation Emphasizes legitimacy of objective over subjective data Pros and Cons of SOAP Charting *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 – Intervention • M – Monitoring • E - 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 needs • Should 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. Intervention • What 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 symptoms • Weight • Intake • Lab values • Clinical symptoms

36. Example of ADIME • A - 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-5.10.2) related to frequent use of restaurant foods as evidenced by diet history.

37. Example of ADIME • I – 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 Note • Brief summary of progress, data, action in a paragraph format • Frequently used to document brief interventions or follow-ups to initial assessments • Nutrition 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 lb 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. 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 concurrently • Entries are more legible, making errors less likely • Data 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 home • Ht: 5 ft. 3 in; weight 184 lb. BMI 32.6; • Meds: Toprol 20 mg b.i.d.; no meds for diabetes at present • Labs: 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 program • Consulted 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 provider • There 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 common • Well-designed CMRs allow clinicians to easily access and organize the information they need without repetition • Most CMRs are designed around the needs of physicians and nurses • Nutrition care professionals should be assertive in shaping the final product to meet their needs

44. Mercy Medical Center Meditech Charting: Nutrition Assessment

45. Mercy Medical Center Initial Assessment (cont)

46. Mercy Medical Center Initial Assessment (cont)

47. Mercy Medical Center Meditech Charting: Nutrition Assessment

48. Mercy Medical Center Meditech Charting Reassessment

49. Mercy Medical Center Meditech Charting Reassessment

50. Aultman Hospital Nutrition Progress Notes