Date of this Version
Published in Journal of the American Dietetic Association 105:10 (October 2005), pp. 1582–1589; doi: 10.1016/j.jada.2005.07.004
Objective — To compare documentation of two groups of clinical nutrition practitioners for evidence of the nutrition care process.
Design — This study used a comparative descriptive design. A retrospective chart review was conducted on all nutrition documentation in closed patient records. Documentation of two groups of nutrition practitioners (institution A = practitioners who received initial orientation and routine reinforcement in use of nutrition care process standards; institution B = practitioners who received orientation in use of a further assessment and medical nutrition therapy intervention procedure) was compared for evidence of a six-step nutrition care process.
Sample/Setting — The sample consisted of randomly selected patient records (N = 60). A total of 15 oncology and 15 chronic renal failure patient records from each of two Midwestern tertiary- care hospitals were reviewed.
Main Outcome Measures — Outcome measures were number of nutrition care process steps documented, appropriate relationships among documented steps in the nutrition care process, and the number of complete, incomplete, and interrupted chains.
Statistical Analyses — Two-sample t tests and χ2 analyses were used.
Results — Nutrition practitioners at institution A documented approximately three times as many nutrition care process steps per patient per chain that demonstrated appropriate relationships as did nutrition practitioners at institution B (2.69 ± 1.15 and 0.80 ± 0.62, respectively [mean ± standard deviation]) (P < .001). There were no outcome judgments related to goals documented in chains at either institution and because of this there were no completed nutrition care process chains at either institution.
Conclusions — Nutrition practitioners with orientation to nutrition care process standards documented more related nutrition care process steps than practitioners without this orientation. Providing nutrition practitioners with ongoing education and clinical experiences in use and documentation of the nutrition care process and a standardized language may be indicated to increase the number of completed nutrition care process chains and improve documentation of nutrition care and patient outcomes.