Charting/NCP

Charting a Patient is Entering Information Into Their 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 (HIPAA)

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

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

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

Other information Flow sheets that often summarize vital signs, inputs and outputs, etc Informed consent forms Radiologic images, EKG tracings, outputs from medical devices

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.

Why is Nutrition Care Documentation Important? Quality assurance Communication Health care team Verifies care given JCAHO accreditation Peer review State audits

What do I include in the 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

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)

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

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

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

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

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).

Pros and Cons of SOAP Charting 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 *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.

Let’s Talk About the NCP

ADIME Developed to facilitate the NCP A – Assessment D – Diagnosis I – Intervention M – Monitoring E - Evaluation

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

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

Nutrition diagnosis step is articulated in PES Statement Problem… related to…Etiology… as evidenced by…Signs or symptoms

Evaluating your PES statement There are no “right” or “wrong” PES statements But …. Some are better than others!! Questions have been developed for you to use when evaluating your PES statement

Evaluating your PES statement Can the RD resolve or improve the nutrition diagnosis ? Consider the intake domain as the preferred problem E Is the etiology the “root” cause? Will intervention resolve the problem by addressing the etiology? Can RD intervention at least lessen the signs and symptoms? S Will measuring the s/s indicate if resolved or improved? Are the signs and symptoms specific enough? PES Overall Does nutrition assessment data support the nutrition diagnosis, etiology, and signs and symptoms?

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)

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

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.

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)

Questions?