The Medical Record and Documentation of Nutrition Care

Medical Record

• Is a systematic documentation of a patient’s Is a systematic documentation of a patient’s medical history and caremedical history and care

• Used both for the physical document and Used both for the physical document and the body of information that comprises the the body of information that comprises the person’s health historyperson’s health history

• Intensely personal documents; many issues Intensely personal documents; many issues around access, storage, and disposalaround access, storage, and disposal

Parts of the Medical Record

• Demographics/legal informationDemographics/legal information• Medical historyMedical history• Medical encountersMedical encounters• OrdersOrders• Progress notesProgress notes• Test resultsTest results• Other informationOther information

Demographics

• Non-medical informationNon-medical information• Identifying numbers, addresses, contact Identifying numbers, addresses, contact

numbersnumbers• Information about race and religious Information about race and religious

preference, occupationpreference, occupation• Health insurance informationHealth insurance information• Emergency contactsEmergency contacts

Medical History

• Surgical history – chronicle of surgery performed Surgical history – chronicle of surgery performed on the patient; may include dates of surgery, on the patient; may include dates of surgery, operative reports, etcoperative reports, etc

• Obstetric history – lists prior pregnancies and their Obstetric history – lists prior pregnancies and their outcomes; complications of pregnancyoutcomes; complications of pregnancy

• Medication and medical allergies – summary of Medication and medical allergies – summary of the patient’s current and previous medications and the patient’s current and previous medications and allergies to medicationsallergies to medications

• Family history – health status of immediate family Family history – health status of immediate family members and causes of death; diseases common in members and causes of death; diseases common in the family; important for predicting risk of certain the family; important for predicting risk of certain genetic or chronic diseasesgenetic or chronic diseases

Medical History

• Social history – chronicle of human Social history – chronicle of human interactions; important relationships, interactions; important relationships, education, career and financial status, education, career and financial status, community and family supportcommunity and family support

• Habits – that impact health, such as tobacco Habits – that impact health, such as tobacco use, alcohol intake, recreational drug use, use, alcohol intake, recreational drug use, activity, and diet; may address sexual habits activity, and diet; may address sexual habits and sexual preferencesand sexual preferences

Medical History

• Immunization history – history of Immunization history – history of immunizationsimmunizations

• Growth chart and developmental history, Growth chart and developmental history, including comparison to other children of including comparison to other children of the same age and genderthe same age and gender

• Addresses developmental milestones such Addresses developmental milestones such as walking, talking, etc. as walking, talking, etc.

Medical Encounters

• Summary of an episode of careSummary of an episode of care• Outpatient or inpatient admissionOutpatient or inpatient admission• Includes:Includes:

• Chief complaintChief complaint• History of the present illnessHistory of the present illness• Physical examPhysical exam• Assessment and planAssessment and plan

Orders

• Written orders by medical providers – Written orders by medical providers – physicians (residents or attendings) and physicians (residents or attendings) and nurse practitioners; others with order nurse practitioners; others with order writing privilegeswriting privileges

• Must be signedMust be signed• Can find diet orders, lab orders, Can find diet orders, lab orders,

medications, enteral and parenteral ordersmedications, enteral and parenteral orders

Progress Notes

• Daily updates entered into the medical record Daily updates entered into the medical record documenting clinical changes, new information, documenting clinical changes, new information, results of testsresults of tests

• May be in SOAP, narrative, or other formatsMay be in SOAP, narrative, or other formats• Generally entered by all members of the health Generally entered by all members of the health

care team (doctors, nurses, physical therapists, care team (doctors, nurses, physical therapists, dietitians, pharmacistsdietitians, pharmacists

• Kept in chronological orderKept in chronological order

Test Results

• Blood tests, Blood tests, radiology exams, radiology exams, pathology, pathology, specialized testingspecialized testing

• Often accessed Often accessed online, even where online, even where there is a paper there is a paper medical recordmedical record

Other information

• Flow sheets that often summarize vital Flow sheets that often summarize vital signs, inputs and outputs, etcsigns, inputs and outputs, etc

• Informed consent formsInformed consent forms• Radiologic images, EKG tracings, outputs Radiologic images, EKG tracings, outputs

from medical devicesfrom medical devices

Nutritional Care Record

• Written documentation of the nutritional Written documentation of the nutritional care process, including the interventions care process, including the interventions and activities used to meet the nutritional and activities used to meet the nutritional objectivesobjectives

• ““If it’s not documented, it didn’t happen.”If it’s not documented, it didn’t happen.”• Medical record is a legal document.Medical record is a legal document.

Nutrition Care Documentation

1.1. Quality assuranceQuality assurance

2.2. CommunicationCommunication

1.1. Health care teamHealth care team

2.2. Verifies care givenVerifies care given

3.3. JCAHO accreditationJCAHO accreditation

4.4. Peer reviewPeer review

5.5. State auditsState audits

Medical Record Documentation

• All entries should be written in black pen or All entries should be written in black pen or typewrittentypewritten

• Documentation should be complete, clear, Documentation should be complete, clear, concise, objective, legible, and accurateconcise, objective, legible, and accurate

• Entries should include the date, time, and Entries should include the date, time, and serviceservice

• Complete sentences are not necessary, but Complete sentences are not necessary, but grammar and spelling should be correctgrammar and spelling should be correct

Medical Record Documentation

• Abbreviations that are unclear or which Abbreviations that are unclear or which have multiple meanings should be avoidedhave multiple meanings should be avoided

• Most institutions have an approved list of Most institutions have an approved list of allowed abbreviationsallowed abbreviations

• JCAHO has a list of forbidden JCAHO has a list of forbidden abbreviations which have been associated abbreviations which have been associated with medical errors in the pastwith medical errors in the past

Medical Record Documentation

• Personal opinions, comments critical or casting Personal opinions, comments critical or casting doubt on other team members (e.g. “chart wars”) doubt on other team members (e.g. “chart wars”) should be avoidedshould be avoided

• Documentation should be done at the time the Documentation should be done at the time the service or procedure is performed; it should never service or procedure is performed; it should never be done in advancebe done in advance

• All entries should be signed at the end and include All entries should be signed at the end and include credentials. In some institutions, chart notes will credentials. In some institutions, chart notes will include pager numbers or PIN numbersinclude pager numbers or PIN numbers

Medical Record Documentation• No one should ever chart or sign the medical No one should ever chart or sign the medical

record for someone elserecord for someone else• Late entries should be identified as such, including Late entries should be identified as such, including

the actual date and time of the entry and the date the actual date and time of the entry and the date and time it should have been documentedand time it should have been documented

• When making corrections, do not obliterate the When making corrections, do not obliterate the original entry. Draw a single line through it, note original entry. Draw a single line through it, note “error” and correct it, listing the date and time of “error” and correct it, listing the date and time of the correction and your initialsthe correction and your initials

Verbal/Telephone Orders

• Verbal/Telephone orders: orders dictated over the Verbal/Telephone orders: orders dictated over the phone or in person to a person qualified to receive phone or in person to a person qualified to receive them; these are then documented in the medical them; these are then documented in the medical record and implemented prior to physician signaturerecord and implemented prior to physician signature

• Most institutions require that verbal/telephone Most institutions require that verbal/telephone orders be signed by the physician or provider within orders be signed by the physician or provider within 24 hours24 hours

• Verbal/telephone orders should never be accepted Verbal/telephone orders should never be accepted from a provider who is physically present and able to from a provider who is physically present and able to write the order him/herselfwrite the order him/herself

Order Writing Privileges• This allows non-physician licensed professionals This allows non-physician licensed professionals

to write orders within a given scope of practice to write orders within a given scope of practice which are implemented without physician co-which are implemented without physician co-signature signature

• For nutrition professionals, this might include For nutrition professionals, this might include changes in diet orders, ordering of lab tests changes in diet orders, ordering of lab tests pertinent to nutrition care, and making changes in pertinent to nutrition care, and making changes in parenteral or enteral regimensparenteral or enteral regimens

• Sometimes order writing privileges are delegated Sometimes order writing privileges are delegated in the context of a protocol, which clearly defines in the context of a protocol, which clearly defines indications and interventionsindications and interventions

Verbal Orders and Order Writing Privileges• Dietitian acceptance of verbal/phone orders Dietitian acceptance of verbal/phone orders

from providers and use of order writing from providers and use of order writing privileges may be dictated by state law privileges may be dictated by state law and/or institutional policy (generally and/or institutional policy (generally medical staff bylaws)medical staff bylaws)

• Acceptance of verbal/phone orders may be Acceptance of verbal/phone orders may be limited by institutional policy to orders limited by institutional policy to orders pertaining to nutritional carepertaining to nutritional care

Documentation Styles• ADIME (assessment, diagnosis, intervention, ADIME (assessment, diagnosis, intervention,

monitoring and evaluation)monitoring and evaluation)• DAP (diagnosis, assessment, plan)DAP (diagnosis, assessment, plan)• DAR (data, action, response)DAR (data, action, response)• PIE (problem, intervention, evaluation)PIE (problem, intervention, evaluation)• PES (problem, etiology, symptoms)PES (problem, etiology, symptoms)• IER (intervention, evaluation, revision)IER (intervention, evaluation, revision)• HOAP (history, observation, assessment, plan)HOAP (history, observation, assessment, plan)• SAP (screen, assess, plan)SAP (screen, assess, plan)• SOAPIER (subjective, objective, SOAPIER (subjective, objective,

analysis/assessment, plan, intervention, evaluation, analysis/assessment, plan, intervention, evaluation, revisions)revisions)

• SOAP (subjective, objective, assessment, plan)SOAP (subjective, objective, assessment, plan)

SOAP NotesS: SubjectiveS: Subjective• Info provided by patient, family, or otherInfo provided by patient, family, or other• Pertinent socioeconomic, cultural infoPertinent socioeconomic, cultural info• Level of physical activity Level of physical activity • Significant nutritional history: usual eating Significant nutritional history: usual eating

pattern, cooking, dining outpattern, cooking, dining out• Work scheduleWork schedule

SOAP Notes—cont’dO: ObjectiveO: Objective• Factual, reproducible observationsFactual, reproducible observations• DiagnosisDiagnosis• Height, age, weight—and weight gain/loss Height, age, weight—and weight gain/loss

patternspatterns• Lab dataLab data• Clinical data (nausea, diarrhea)Clinical data (nausea, diarrhea)• Diet orderDiet order• MedicationsMedications• Estimation of nutritional needsEstimation of nutritional needs

SOAP Notes—cont’d

A: AssessmentA: Assessment• Nutrition diagnosisNutrition diagnosis• Interpretation of patient’s status based on subjective Interpretation of patient’s status based on subjective

and objective infoand objective info• Evaluation of nutritional historyEvaluation of nutritional history• Assessment of laboratory data and medicationsAssessment of laboratory data and medications• Assessment of diet orderAssessment of diet order• Assessment of patient’s comprehension and Assessment of patient’s comprehension and

motivationmotivation

SOAP Notes—cont’dP: PlanP: Plan• Diagnostic studies neededDiagnostic studies needed• Further workup, data neededFurther workup, data needed• Medical nutrition therapy goalsMedical nutrition therapy goals• Education plansEducation plans• Recommendations for nutritional careRecommendations for nutritional care

SOAP EXAMPLE• S: Patient works night shift, eats two meals a day, before S: Patient works night shift, eats two meals a day, before

and after his shift; fried foods, burgers, ice cream, beers and after his shift; fried foods, burgers, ice cream, beers in restaurants. Does not add salt to foods. Activity: in restaurants. Does not add salt to foods. Activity: Plays golf 1x month.Plays golf 1x month.

• O: 34 y.o. male s/p MI with history of htn, DM2, O: 34 y.o. male s/p MI with history of htn, DM2, hyperlipidemia. hyperlipidemia. • Ht: 5 ft. 10 in; wt: 250 lb; BMI 36, Obesity IIHt: 5 ft. 10 in; wt: 250 lb; BMI 36, Obesity II

• A: Excessive sodium intake (NI-5.10.2) related to A: Excessive sodium intake (NI-5.10.2) related to frequent use of vending foods as evidenced by diet frequent use of vending foods as evidenced by diet history. Pt could benefit from increased activity and history. Pt could benefit from increased activity and gradual wt loss as recovery allowsgradual wt loss as recovery allows

• P: Provided basic education (E-1) on 3-4 gram sodium P: Provided basic education (E-1) on 3-4 gram sodium diet and wt management guidelinesdiet and wt management guidelines• Patient will return to outpatient nutrition clinic for Patient will return to outpatient nutrition clinic for

lifestyle intervention and counseling (C-2.1). lifestyle intervention and counseling (C-2.1).

Pros and Cons of SOAP Charting

PROSPROS• Common use by nutrition Common use by nutrition

care professionals and care professionals and other disciplinesother disciplines

• Taught in most dietetics Taught in most dietetics education programseducation programs

• Easy to learn and utilizeEasy to learn and utilize

CONSCONS• Tends to encourage lengthy Tends to encourage lengthy

chart noteschart notes• One study suggests One study suggests

physicians are less likely to physicians are less likely to respond to this format than respond to this format than others*others*

• Downplays evaluationDownplays evaluation• Emphasizes legitimacy of Emphasizes legitimacy of

objective over subjective objective over subjective datadata

*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.

ADIME

Developed to facilitate the NCPDeveloped to facilitate the NCP• A – AssessmentA – Assessment• D – DiagnosisD – Diagnosis• I – InterventionI – Intervention• M – MonitoringM – Monitoring• E - EvaluationE - Evaluation

Assessment (A)

• All data pertinent to clinical decision All data pertinent to clinical decision making, including diet history, medical making, including diet history, medical history, medications, physical assessment, history, medications, physical assessment, lab values, current diet order, estimated lab values, current diet order, estimated nutritional needsnutritional needs

• Should include relevant data onlyShould include relevant data only

Diagnosis

• Should include PES statement for nutrition Should include PES statement for nutrition diagnosisdiagnosis

• Patients may have more than one diagnosis, Patients may have more than one diagnosis, but try to choose the one or two most but try to choose the one or two most pertinent, or the ones you mean to addresspertinent, or the ones you mean to address

Intervention• What do you recommend or plan to do to What do you recommend or plan to do to

address the nutrition diagnoses?address the nutrition diagnoses?• Recommend change in food-nutrient delivery Recommend change in food-nutrient delivery

(supplement, change in diet, nutrition (supplement, change in diet, nutrition support, vitamin-mineral supplement) (NI)support, vitamin-mineral supplement) (NI)

• Nutrition education (E)Nutrition education (E)• Nutrition counseling (C)Nutrition counseling (C)• Coordination of nutrition care (RC)Coordination of nutrition care (RC)

Monitoring and Evaluation (ME)

• What will you monitor to determine if the What will you monitor to determine if the nutrition intervention was successful?nutrition intervention was successful?

• Generally based on the signs and symptomsGenerally based on the signs and symptoms• WeightWeight• IntakeIntake• Lab valuesLab values• Clinical symptomsClinical symptoms

Example of ADIME

• A - 34 y.o. male s/p MI with history of htn, DM2, A - 34 y.o. male s/p MI with history of htn, DM2, hyperlipidemia; ht: 5 ft. 10 in; wt: 250 lb; BMI 36, hyperlipidemia; ht: 5 ft. 10 in; wt: 250 lb; BMI 36, obesity II. Patient works night shift, eats two obesity II. Patient works night shift, eats two meals a day, before and after his shift--fried foods, meals a day, before and after his shift--fried foods, burgers, ice cream, beers in restaurants.. Does not burgers, ice cream, beers in restaurants.. Does not add salt to foods. Activity: Plays golf 1x month.add salt to foods. Activity: Plays golf 1x month.

• D - Excessive energy intake (NI-1.5); excessive D - Excessive energy intake (NI-1.5); excessive sodium intake (NI-5.10.2) related to frequent use sodium intake (NI-5.10.2) related to frequent use of restaurant foods as evidenced by diet history. of restaurant foods as evidenced by diet history.

Example of ADIME

• I – Provided basic education (E-1) on 3-4 gram I – Provided basic education (E-1) on 3-4 gram sodium diet and wt. management guidelines sodium diet and wt. management guidelines (nutrition education); pt to return to outpatient (nutrition education); pt to return to outpatient nutrition clinic for lifestyle intervention (C-2.1)nutrition clinic for lifestyle intervention (C-2.1)

• ME – Evaluate weight (S-1.1.4), blood pressure ME – Evaluate weight (S-1.1.4), blood pressure (S-3.1.7), diet history at outpatient visit sodium (S-3.1.7), diet history at outpatient visit sodium intake (FI-6.2); energy intake (FI1.1.1); fat intake intake (FI-6.2); energy intake (FI1.1.1); fat intake (FI-5.1.1) Re-check lipids in 3 months (S-2.6)(FI-5.1.1) Re-check lipids in 3 months (S-2.6)

Narrative Note

• Brief summary of progress, data, action in Brief summary of progress, data, action in a paragraph formata paragraph format

• Frequently used to document brief Frequently used to document brief interventions or follow-ups to initial interventions or follow-ups to initial assessmentsassessments

• Nutrition professionals may use for same Nutrition professionals may use for same purpose or to document food preference purpose or to document food preference interviews, response to a patient question or interviews, response to a patient question or complaint, re-screening of low risk ptscomplaint, re-screening of low risk pts

Brief Narrative Note Example34 y.o. male s/p MI with history of htn, DM2, 34 y.o. male s/p MI with history of htn, DM2, hyperlipidemia. Ht: 5 ft. 10 in; wt: 250 lb hyperlipidemia. Ht: 5 ft. 10 in; wt: 250 lb Patient works night shift, eats two meals a day, Patient works night shift, eats two meals a day, before and after his shift, fried foods, burgers, before and after his shift, fried foods, burgers, ice cream, beers in restaurants. Does not add salt ice cream, beers in restaurants. Does not add salt to foods. to foods.

Nutrition diagnosis: Excessive energy intake Nutrition diagnosis: Excessive energy intake (NI-1.5) related to high intake of fat and (NI-1.5) related to high intake of fat and restaurant foods aeb BMI and diet history. restaurant foods aeb BMI and diet history. Response (Evaluation) Pt was able to list high Response (Evaluation) Pt was able to list high sodium foods and appropriate diet changes (BE-sodium foods and appropriate diet changes (BE-2.2.1) 2.2.1)

Electronic Medical Record

• Many health care institutions are Many health care institutions are implementing electronic medical records implementing electronic medical records (Aultman and Mercy Medical Center) (Aultman and Mercy Medical Center)

• All disciplines can access the patient chart All disciplines can access the patient chart concurrentlyconcurrently

• Entries are more legible, making errors less Entries are more legible, making errors less likelylikely

• Data can be organized to support clinical Data can be organized to support clinical decision makingdecision making

Charting Format Case Study• MJ is a 75 y.o. African-American female with PMH of MJ is a 75 y.o. African-American female with PMH of

HTN and DM admitted with cellulitis of right foot. She is HTN and DM admitted with cellulitis of right foot. She is retired and active in her church. She does not get around retired and active in her church. She does not get around much due to arthritis in her knees. Follows no special diet much due to arthritis in her knees. Follows no special diet at home; eats breakfast at Bob Evans daily; biscuits and at home; eats breakfast at Bob Evans daily; biscuits and sausage gravy, eggs, and grits. sausage gravy, eggs, and grits.

• ““The doctor said I had a little sugar; I don’t eat much The doctor said I had a little sugar; I don’t eat much bakery.” bakery.”

• Does not test glucose at homeDoes not test glucose at home• Ht: 5 ft. 3 in; weight 184 lb. BMI 32.6; Ht: 5 ft. 3 in; weight 184 lb. BMI 32.6; • Meds: Toprol 20 mg b.i.d.; no meds for diabetes at presentMeds: Toprol 20 mg b.i.d.; no meds for diabetes at present• Labs: TC: 250; LDL-C: 180 mg/dl; A1C: 9%; Labs: TC: 250; LDL-C: 180 mg/dl; A1C: 9%; • ECR at current weight: 2000 kcals; ECR at current weight: 2000 kcals; • Provided survival skills information regarding nutrition Provided survival skills information regarding nutrition

therapy for diabetes; referred to diabetes self management therapy for diabetes; referred to diabetes self management programprogram

• Consulted diabetes educator to obtain home monitor. Consulted diabetes educator to obtain home monitor.

Charting Format Issues• Nutrition care documentation is unique in Nutrition care documentation is unique in

that it is often consultative, intended to that it is often consultative, intended to elicit action (orders) on the part of the elicit action (orders) on the part of the providerprovider

• There is little data to demonstrate the There is little data to demonstrate the efficacy of one chart format over another in efficacy of one chart format over another in conveying recommendations to physicians, conveying recommendations to physicians, communicating with other team members, communicating with other team members, and meeting legal and regulatory and meeting legal and regulatory requirementsrequirements

Chart Formats and Computerized Medical Records (CMRs)

• Charting formats will likely dwindle in Charting formats will likely dwindle in importance as computerized medical records importance as computerized medical records become more commonbecome more common

• Well-designed CMRs allow clinicians to easily Well-designed CMRs allow clinicians to easily access and organize the information they need access and organize the information they need without repetitionwithout repetition

• Most CMRs are designed around the needs of Most CMRs are designed around the needs of physicians and nursesphysicians and nurses

• Nutrition care professionals should be assertive in Nutrition care professionals should be assertive in shaping the final product to meet their needsshaping the final product to meet their needs

Mercy Medical Center Meditech Charting: Nutrition Assessment

Mercy Medical Center Initial Assessment (cont)

Mercy Medical Center Initial Assessment (cont)

Mercy Medical Center Meditech Charting: Nutrition Assessment

Mercy Medical Center Meditech Charting Reassessment

Mercy Medical Center Meditech Charting Reassessment

Aultman Hospital

Nutrition Progress Notes

Aultman

Hospital

Nutrition

Progress

Notes