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Nutrition Informatics Blog

Longing for the Day of a Standardized Nutrition Documentation Process

(What is Nutrition Informatics, Clinical Nutrition) Permanent link   All Posts

Submitted by Jan Greer-Carney, MS, MBA, RD, LD

 

The 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.

A 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).

However, 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.

Oh, 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!


A well-designed EHR allows for both free text and structured data entry. While we have a well-designed care process (the NCP), we shouldn't require rigid documentation formats at the individual level.
The way your documentation looks is something that's a problem for all of us and isn't fixed by simply requiring structured data entry.

There's a lot of controversy over this in healthcare. Many feel that too heavy reliance on structured data entry takes away the provider's ability to "tell the rich story" that is patient care at its core.

It should be possible to find the happy medium and still be meaningfully happy!
Posted by: Pam Charney at 4/3/2013 12:41 PM


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