The document discusses guidelines for proper documentation of patient care in medical records. It covers the purposes of medical charting such as providing a systematic record of care, facilitating quality improvement, and meeting legal requirements. Both electronic medical records and paper charting methods like SOAP notes are addressed. The importance of using standardized language and formatting is emphasized. Guidelines are provided for issues like maintaining confidentiality, detailing objective observations, and following institutional protocols.

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Nutrition Therapy and Pathophysiology | 3e
Nelms | Sucher | Lacey | Roth
R. Gerald Nelms, PhD
Wright State University
Documentation of the Nutrition
Care Process
Chapter 6

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Charting: Documentation of the
Nutrition Care Process
• Documentation in the medical record
– Systematic recording of patients’ care
– Ongoing conversation
– Clear and comprehensive record
– Continuous quality improvement
– Current procedural terminology (CPT) codes
– Use of terminology consistent with prospective
payment system
– Legal documentation

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Purposes of Medical Record
Charting

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Electronic Medical Records
• Application environment
• Supports patient’s medical record across
inpatient and outpatient settings
• Advantages
– Expedited transcription and delivery of
physician orders, reduction of errors,
improvement in patient safety, and facilitation
of achieving positive patient outcomes
• Disadvantage
– Inconsistencies across systems

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An EMR Template

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Documentation of the Nutrition
Care Process
• Standardized language and medical
abbreviations
– JCAHO: see abbreviations not to use (Table
6.2)
– Use nutrition diagnostic terminology
• POMR – problem-oriented medical record
– Data, problem list, care plan, progress notes,
and discharge summary

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The Joint Commission Official “Do
Not Use” List

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Organization of Nutrition
Documentation
• SOAP
– Subjective data
– Objective data
– Assessment
– Plan
• PES: problem, etiology, and
signs/symptoms
– Documentation of the nutrition diagnosis

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ADIM and IER
• Assessment, diagnosis, intervention, and
monitoring/evaluation (ADIM)
– Reflects nutrition care process
– D section includes PES statements
• IER notes
– Simplified SOAP
– Intervention, evaluation, and revision of care

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Focus, PIE, and CBE
• Focus notes
– Blending of SOAP and IER formats
• PIE notes
– Problem, intervention, and evaluation
• Charting by exception (CBE)
– Recording only unusual or out-of-the ordinary
events

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Keeping a Personal Medical
Notebook
• Create your own system of keeping notes
for brainstorming problems and expressing
own responses
• Follow a standard format or invent your
own
• Keep it confidential

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Guidelines for All Charting
• Chart what you see as significant
• Sign with full name and status
• Be timely
• Do you own charting; never chart for
anyone else
• Do not chart procedure until it is
completed
• Remember: charts are legal as well as
medical documents

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Charting Guidelines:
Style/Formatting
• If charting by hand, use black ink
• Write clearly so the meaning of your note
is clear
• Avoid abbreviations unless you are certain
they will be immediately understandable
• If handwriting, begin your note
immediately after the previous note; do not
leave white space

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Charting Guidelines: Content
• Include too much detail rather than too
little
• When writing objective notes, do not
assume or infer
• Set aside biases
• Use neutral language
• Use “patient” or “client” rather than name

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Charting Guidelines: Protocols
• Always keep record intact
• Cross out mistakes with single horizontal
line; write word “error” above it
• Sign notes after printing name
(electronically or by hand)
• Include date and time
• Follow agency’s or institution’s guidelines

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Confidentiality
• In U.S., Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
– Protects information about clients that is
gathered by examination, observation,
conversation, or treatment

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Beyond Charting: Functions
• Record information
• Inform
• Persuade
• Entertain

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Beyond Charting: Rhetorical Norms
• Rhetorical norms
– Subject matter
– Purpose
– Audience
– Ethos
• Levels of discourse

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Beyond Charting: The Writing and
Reporting Process
• Steps in the writing process
– Prewriting or invention
– Drafting
– Revision
– Editing
• Report your own research

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Conclusions: Your Ethos-
Establishing Expertise
• Follow code of ethics: your professional
obligation is to convey accurate
information for all audiences
• Take continued professional education
• Draw on ongoing knowledge