Charting/NCP

Charting a Patient is Entering Information Into Their Medical RecordIs a systematic documentation of a patient’s

medical history and careUsed 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)

Parts of the Medical RecordDemographics/legal informationMedical historyMedical encountersTest resultsOrdersProgress notesOther information

OrdersWritten orders by medical providers –

physicians (residents or attendings) and nurse practitioners; others with order writing privileges

Must be signedCan find diet orders, lab orders,

medications, enteral and parenteral orders

Progress NotesDaily 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

Other informationFlow sheets that often summarize vital

signs, inputs and outputs, etcInformed consent formsRadiologic images, EKG tracings, outputs

from medical devices

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.

Why is Nutrition Care Documentation Important?

1. Quality assurance2. Communication

1. Health care team2. Verifies care given3. JCAHO accreditation4. Peer review5. State audits

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

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)

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

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

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

SOAP Notes—cont’d

P: Plan Diagnostic studies needed Further workup, data needed Medical nutrition therapy goals Education plans Recommendations for nutritional care

SOAP EXAMPLES: 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-5.10.2) 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 guidelinesPatient will return to outpatient nutrition

clinic for lifestyle intervention and counseling (C-2.1).

Pros and Cons of SOAP ChartingPROSCommon use by

nutrition care professionals and other disciplines

Taught in most dietetics education programs

Easy to learn and utilize

CONSTends to encourage

lengthy chart notesOne study suggests

physicians are less likely to respond to this format than others*

Downplays evaluationEmphasizes

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.

Let’s Talk About the NCP

ADIMEDeveloped to facilitate the NCPA – AssessmentD – DiagnosisI – InterventionM – MonitoringE - Evaluation

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

DiagnosisShould include PES statement for nutrition

diagnosisPatients may have more than one

diagnosis, but try to choose the one or two most pertinent, or the ones you mean to address

Nutrition diagnosis step isarticulated in PES StatementPES Statement =Problem…

related to…Etiology…o as evidenced by…Signs or symptoms

Evaluating your PES statementThere are no “right” or “wrong” PES

statementsBut ….Some are better than others!!Questions have been developed for you to

use when evaluating your PES statement

Evaluating your PES statement PCan the RD resolve or improve the nutrition diagnosis ?Consider the intake domain as the preferred problemEIs the etiology the “root” cause?Will intervention resolve the problem by addressing

the etiology?Can RD intervention at least lessen the signs and

symptoms?SWill measuring the s/s indicate if resolved or

improved?Are the signs and symptoms specific enough?PES OverallDoes nutrition assessment data support the nutrition

diagnosis, etiology, and signs and symptoms?

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)

Monitoring and Evaluation (ME)What will you monitor to determine if the

nutrition intervention was successful?Generally based on the signs and

symptomsWeightIntakeLab valuesClinical symptoms

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-5.10.2) related to frequent use of restaurant foods as evidenced by diet history.

Example of ADIMEI – 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-3.1.7), 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)

Questions?