Submitted by Jan Greer-Carney, MS, MBA, RD, LD
Nutrition Care Process is a wonderful tool for nutrition professionals. It
allows us to organize our assessment, nutrition diagnosis, intervention, and
monitoring/evaluation in a standardized fashion. If this information is entered
into the electronic health record as structured data, then we can mine our data
and begin to show the value of our interventions. This can only mean greater respect
for our field, which will hopefully translate into better salaries too. It is a
shame that it is not such a simple process.
nutrition module is not included in the electronic health record package, so we
get to design our own nutrition documentation screens. That sounds kind of
nice, like we will actually get what we want, rather than what someone thinks
we want (even though the designer does not even know what we do).
the reality is that we each create a documentation process that the system we
are using allows us to create. We enter our data, checking the appropriate
boxes and free-texting information without a desired box. When we go to look at
the charted information, it looks nothing like what we think we entered. It is easy
to see why the provider does not read our notes.
for the day when we get a nutrition documentation process that is standardized,
one that results in charted information that is actually meaningful. Then we
can appreciate meaningful use!