DOCUMENTATION OF NCPInggita Kusumastuty, S.Gz, M.Biomed*

Medical RecordIs a systematic documentation of a patients medical history and careUsed both for the physical document and the body of information that comprises the persons health historyIntensely personal documents; many issues around access, storage, and disposal*

Nutritional Care RecordWritten documentation of the nutritional care process, including the interventions and activities used to meet the nutritional objectivesIf its not documented, it didnt happen.Medical record is a legal document.*

Catatan Asuhan GiziPendokumentasian NCP menguntungkan :Menjamin asuhan gizi lebih relevan, lengkap dan efektif oleh karena didasarkan atas problemMemberikan kesempatan tim kesehatan yang lain memahami masalah dan intervensinyaMemberikan kesempatan tim yang lain berpartisipasi dalam proses intervensi.

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Documentation StylesADIME (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)*

Chart Note

S = SubjectiveO = ObjectiveA = AssessmentP = PlanDx = Plan for additional diagnosis or assessmentRX = Plan for treatmentPtEd = Plan for patient education

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SOAP NotesS: SubjectiveInfo provided by patient, family, or otherPertinent socioeconomic, cultural infoLevel of physical activity Significant nutritional history: usual eating pattern, cooking, dining outWork schedule*

SOAP NotescontdO: ObjectiveFactual, reproducible observationsDiagnosisHeight, age, weightand weight gain/loss patternsLab dataClinical data (nausea, diarrhea)Diet orderMedicationsEstimation of nutritional needs*

SOAP NotescontdA: AssessmentNutrition diagnosisInterpretation of patients status based on subjective and objective infoEvaluation of nutritional historyAssessment of laboratory data and medicationsAssessment of diet orderAssessment of patients comprehension and motivation*

SOAP NotescontdP: PlanDiagnostic studies neededFurther workup, data neededMedical nutrition therapy goalsEducation plansRecommendations for nutritional care*

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

PAPER FORM VS ELECTRONIC MEDICAL RECORD

PAPER FORM*

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ELECTRONIC MEDICAL RECORD *

EXAMPLE :CHARTING NUTRITION ASSESSMENT(Mercy Medical Center Meditech)*

Mercy Medical Center Meditech Charting: Nutrition Assessment*

Mercy Medical Center Initial Assessment (cont)*

Mercy Medical Center Initial Assessment (cont)*

Mercy Medical Center Meditech Charting: Nutrition Assessment*

Mercy Medical Center Meditech Charting Reassessment*

Mercy Medical Center Meditech Charting Reassessment*

*THANKS FOR JOIN THIS CLASS

Rekam medis berisi riwayat pasien hingga perawatannya saat ini.. Pada rekam medis merupakan dokumen yang sangat pribadi **Pendokumentasian asuhan gizi meliputi segala aktivitas terkait dengan penetapan intervensi dan tujuan pemberian intervensiMengapa harus didokumentasikan? karena jika tidak terdokumentasi maka hal yang telah direncanakan atau hal yang akan dimonitor atau dievaluasi tidak akan terlaksana.Pendokumentasian asuhan ini memiliki aspek hukum*S = SubjectiveO = ObjectiveA = AssessmentP = PlanDx = Plan for additional diagnosis or assessmentRX = Plan for treatmentPtEd = Plan for patient education*Rencana: rencana untuk diagnosa tambahan, rencana untuk intervensi diet dan edukasi **Subyektif : data yang didapatkan dari pengakuan pasien*Obyektif : data yang didapatkan dari pengukuran*********