Evaluation of nutrition practitioners' documentation for evidence of the nutrition care process in two nutritionally high -risk patient populations

Abstract

The purpose of this project was to compare clinical nutrition practitioners' documentation in patient records for evidence of the nutrition care process at two midwestern tertiary care hospitals. An exploratory, quantitative research design was used to compare documentation of the two groups of practitioners (institution A = practitioners previously received orientation and routine follow up reinforcement in use of the nutrition care process; institution B = practitioners received the standard nutrition assessment and intervention orientation). A random sample of 15 oncology patient records and 15 renal patient records were selected from each of the hospitals. A retrospective chart review was conducted on all nutrition documentation in closed patient records from admission through discharge. A content analysis instrument was designed using the conceptual framework of a six-step nutrition care process, consistent with the scientific method, to collect data from patient records. The outcome measures were the number of nutrition care process steps documented, relationships among documented steps, and the number of complete, incomplete and interrupted nutrition care process chains. Demographic data included patient age, gender, and hospital length of stay. Nutrition practitioners at institution A had significantly more nutrition care process steps documented than practitioners at institution B (t = 7.91, P < 0.001). Diagnoses and etiologies related to evidence (χ² = 26.29, 82.67, respectively, P < 0.001); goals related to diagnosis and etiologies (χ² = 100.37, 57.59, respectively, P < 0.001); and interventions related to goals (χ ² = 52.62, P < 0.001) occurred with greater frequency at institution A compared to institution B. There were no outcome judgments or completed nutrition care process chains identified at either institution. Results indicate that nutrition practitioners who received orientation in use of the nutrition care process documented more components of the nutrition care process. However, deficiencies in documentation by both groups of practitioners identified the need for continued education in both the implementation and documentation of the scientific logic of the nutrition care process to increase the number of completed nutrition care process chains.