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.
clinical nutrition practice
evidence-based nutrition
implementation
nutrition care process
nutrition education
Journal
Journal of human nutrition and dietetics : the official journal of the British Dietetic Association
ISSN: 1365-277X
Titre abrégé: J Hum Nutr Diet
Pays: England
ID NLM: 8904840
Informations de publication
Date de publication:
24 Jan 2024
24 Jan 2024
Historique:
received:
25
08
2023
accepted:
31
12
2023
medline:
25
1
2024
pubmed:
25
1
2024
entrez:
25
1
2024
Statut:
aheadofprint
Résumé
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. The audit was performed on 92 EPRs using the Diet-NCP-Audit, which was translated into French for this study. 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. 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.
Sections du résumé
BACKGROUND
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
METHODS
The audit was performed on 92 EPRs using the Diet-NCP-Audit, which was translated into French for this study.
RESULTS
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
CONCLUSIONS
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.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Subventions
Organisme : The Swiss Registered Dieticians Association (ASDD)
Informations de copyright
© 2024 The British Dietetic Association Ltd.
Références
Lacey K, Pritchett E. Nutrition Care Process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003;103:1061-1072.
Hakel-Smith N, Lewis NM, Eskridge KM. Orientation to Nutrition Care Process standards improves nutrition care documentation by nutrition practitioners. J Am Diet Assoc. 2005;105:1582-1589.
Academy of Nutrition and Dietetics. Pocket guide for international dietetics & nutrition terminology (IDNT) reference manual: standardized language for the nutrition care process. Chicago: Academy of Nutrition and Dietetics; 2013.
Bueche J. Nutrition Care Process part II: using the international dietetics and nutrition terminology to document the nutrition care process. J Am Diet Assoc. 2008;108:1287-1293.
Bueche J. Nutrition care process and model part I: the 2008 update. J Am Diet Assoc. 2008;108:1113-1117.
Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26:13-24.
Lövestam E, Orrevall Y, Koochek A, Karlström B, Andersson A. Evaluation of Nutrition Care Process documentation in electronic patient records: need of improvement. Nutr Diet. 2015;72:74-80.
Chui TK, Proaño GV, Raynor HA, Papoutsakis C. A Nutrition Care Process audit of the national quality improvement dataset: supporting the improvement of data quality using the ANDHII platform. J Acad Nutr Diet. 2020;120:1238-48.e1.
Kopp OM. Die Qualität der Dokumentation in der Ernährungsberatung Eine Beurteilung mittels Diet-NCP-Audit Tool. Bern: Berner Fachhochschule; 2019.
Lövestam E, Orrevall Y, Koochek A, Karlström B, Andersson A. Evaluation of a Nutrition Care Process-based audit instrument, the Diet-NCP-Audit, for documentation of dietetic care in medical records. Scand J Caring Sci. 2014;28:390-397.
Lewis SL, Miranda LS, Kurtz J, Larison LM, Brewer WJ, Papoutsakis C. Nutrition Care Process quality evaluation and standardization tool: the next frontier in quality evaluation of documentation. J Acad Nutr Diet. 2022;122:650-660.
Jones NB, Herschel RT, Moesel DD. Using “knowledge champions” to facilitate knowledge management. J Know Manage. 2003;7:49-63.
World Health Organisation. WHODAS 2.0 TRANSLATION PACKAGE (VERSION 1.0). [accessed 8 Apr 2023]. WHODAS 2.0 Translation guidelines.pdf. Available from: https://terrance.who.int/mediacentre/data/WHODAS/Guidelines/WHODAS%202.0%20Translation%20guidelines.pdf
Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, Erikson P. Principles of good practice for the translation and cultural adaptation process for Patient-Reported Outcomes (PRO) measures: report of the ISPOR task force for translation and cultural adaptation. Value Health. 2005;8:94-104.
Heitman K, Proaño GV, Papoutsakis C, Diaque Ballesteros P, Steiber A, Taylor CA. Learning outcomes from a virtual nutrition care process workshop delivered to nutrition and dietetics professionals in Mexico. Top Clin Nutr. 2023;38:113-124.
Lewis S, Miranda L, Kurtz J, Brewer WJ, Papoutsakis C. Harnessing the benefits of the nutrition care process quality evaluation and standardization tool: a national auditing initiative to improve quality of documentation. J Acad Nutr Diet. 2023;123:1662-1668.
Vivanti A, Lewis J, O'Sullivan TA. The Nutrition Care Process Terminology: changes in perceptions, attitudes, knowledge and implementation amongst Australian dietitians after three years. Nutr Diet. 2018;75:87-97.
Lövestam E, Boström AM, Orrevall Y. Nutrition Care Process implementation: experiences in various dietetics environments in Sweden. J Acad Nutr Diet. 2017;117:1738-1748.
Enrione EB, Reed D, Myers EF. Limited agreement on etiologies and signs/symptoms among registered dietitian nutritionists in clinical practice. J Acad Nutr Diet. 2016;116:1178-1186.
Lewis SL, Wright L, Arikawa AY, Papoutsakis C. Etiology intervention link predicts resolution of nutrition diagnosis: a nutrition care process outcomes study from a veterans' health care facility. J Acad Nutr Diet. 2021;121:1831-1840.
Colin C, Arikawa A, Lewis S, Cooper M, Lamers-Johnson E, Wright L, Papoutsakis C. Documentation of the evidence-diagnosis link predicts nutrition diagnosis resolution in the Academy of Nutrition and Dietetics' diabetes mellitus registry study: a secondary analysis of Nutrition Care Process outcomes. Front Nutr. 2023;10:1011958.
Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition Care Process and model update: toward realizing people-centered care and outcomes management. J Acad Nutr Diet. 2017;117:2003-2014.
Murphy WJ, Yadrick MM, Steiber AL, Mohan V, Papoutsakis C. Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII): a pilot study on the documentation of the nutrition care process and the usability of ANDHII by registered dietitian nutritionists. J Acad Nutr Diet. 2018;118:1966-1974.
Maher L, Gustafson D, Evans A. NHS improvement. 2010 [accessed 3 May 2020]. Sustainability model and guide. Available from: https://webarchive.nationalarchives.gov.uk/20160805122935
http://www.nhsiq.nhs.uk/media/2757778/nhs_sustainability_model_-_february_2010_1_.pdf
Zelig R, Byham-Gray L, Touger-Decker R, Parrott JS, Rigassio-Radler D. Impact for continuing education: applying the nutrition care process and model and the international dietetics and nutrition terminology for dietitians in long-term care. Top Clin Nutr. 2011;26:268-280.
Lövestam E, Steiber A, Vivanti A, Boström AM, Devine A, Haughey O, et al. Use of the Nutrition Care Process and Nutrition Care Process Terminology in an international cohort reported by an online survey tool. J Acad Nutr Diet. 2019;119:225-241.
Ansu V, Papoutsakis C, Gletsu-Miller N, Spence LA, Kelley K, Woodcock L, et al. Nutrition care practice patterns for patients with COVID-19-a preliminary report. J Parenter Enteral Nutr. 2021;45:1774-1778.
Lindberg A, Nyberg M, Orrevall Y, Liljeberg E. An audit of dietitians' documentation-comparing the level of agreement between the audit instruments Diet-NCP-Audit and NCP-QUEST. In: Hägglund M, Blusi M, Bonacina S, Nilsson L, Cort Madsen I, Pelayo S, et al., éditors. Studies in Health Technology and Informatics [Internet]. IOS Press; 2023.
Swan WI, Pertel DG, Hotson B, Lloyd L, Orrevall Y, Trostler N, et al. Nutrition Care Process (NCP) update part 2: developing and using the NCP terminology to demonstrate efficacy of nutrition care and related outcomes. J Acad Nutr Diet. 2019;119:840-855.
Müller-Staub M, Needham I, Odenbreit M, Ann Lavin M, Van Achterberg T. Improved quality of nursing documentation: results of a nursing diagnoses, interventions, and outcomes implementation study. Int J Nurs Terminol Classif. 2007;18:5-17.
Fratino A. Implantation du processus de soins en nutrition [Internet]. Montréal: Université de Montréal; 2017. [accessed 14 Jan 2020]. Available from: https://papyrus.bib.umontreal.ca/xmlui/bitstream/handle/1866/18855/Fratino_Adriana_2017_memoire.pdf?sequence=4&isAllowed=y
Shiner R, Galvin A, Roberts SR. The Nutrition Care Process in acute care: identifying common nutrition diagnoses and resolution rate. J Am Diet Assoc. 2010;110(Suppl):A85.
Craig C, Barriero T, Collins S, O'Brien P. Implementation of the Nutrition Care Process and utilization of the international dietetics and nutrition terminology and electronic health record for data generation. J Acad Nutr Diet. 2014;114:A70.
Vivanti A, O'Sullivan TA, Porter J, Hogg M. Successful long-term maintenance following Nutrition Care Process Terminology implementation across a state-wide health-care system. Nutr Diet. 2017;74:372-380.