1. Charting/NCP

2. 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)

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

4. 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

5. 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

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

7. 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.

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

9. 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

10. 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)

11. 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

12. 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

13. 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

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

15. 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 ) 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).

16. 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.

17. Let’s Talk About the NCP

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

19. 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

20. 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

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

22. 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

23. 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?

24. 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)

25. 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

26. 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 ) related to frequent use of restaurant foods as evidenced by diet history.

27. 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 ), 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)

28. Questions?