Nutrition Infographics

What is nutrition informatics?

The effective retrieval, organization, storage, and optimal use of information, data, and knowledge for food- and nutrition-related problem solving and decision making

What did the HITECH Act require?

The use of electronic health records (EHRs) beginning in 2014 in order to receive reimbursement from the Centers for Medicare and Medicaid Services (CMS)

What must an EHR demonstrate according to the HITECH Act?

Improvement in patient care

How do RDNs document in the electronic health record?

Using the Nutrition Care Process with standardized terminology and processes

Why is standardized RDN documentation useful?

It generates data that can show how nutrition interventions improve patient outcomes

What does ANDHII stand for?

Academy of Nutrition and Dietetics Health Informatics Infrastructure

What is ANDHII used for?

Collecting health outcomes data from RDNs and NDTRs in practice

A national quality improvement tool

What does HIPAA protect?

Personal/Protected Health Information (PHI)

Who may access notes about a patient's condition, care, or treatment?

Only individuals who are directly involved in the patient's care

Can accidental disclosure of patient information have consequences?

Yes. Unintentional disclosure can have legal implications

What type of mobile applications should be used for patient information and communication?

Only approved mobile device applications

Why must medical charting be taken seriously?

Medical charts are legal documents

What must every chart entry include?

A date and signature

Electronic medical records automatically date and electronically sign entries

How should time be documented in a paper chart?

Using 24-hour time, such as 1300 for 1:00 PM

When should assessment and plan information be charted?

After the assessment has been completed. Objective information may be charted beforehand

Can you ask someone else to complete your charting?

No. You should never ask someone else to do your charting

What is the healthcare documentation mantra?

“If it isn’t documented, it didn’t happen.”

What are the main purposes of medical record charting?

• Legal documentation of care received

• Communication among healthcare team members

• Evaluation of patient medical care

What are additional uses of medical records?

• Funding/resource management

• Continuous quality improvement

• Third-party reimbursement

• Accreditation

• Research

• Liability protection

Why is standardized language used in nutrition documentation?

To support consistent documentation of the Nutrition Care Process and medical information

Can healthcare workers use any medical abbreviation they want?

No. Facilities have approved acronym lists, and some abbreviations should not be used

What organization maintains a “Do Not Use” abbreviation list?

The Joint Commission/JCAHO

What does SOAP stand for?

• S: Subjective

• O: Objective

• A: Assessment

• P: Plan

What is subjective information?

Information reported by the patient, such as symptoms, feelings, or dietary history

What is objective information?

Measurable or observable information such as lab values, weight, physical findings, or test results

What does ADIME stand for?

• A: Assessment

• D: Diagnosis

• I: Intervention

• M/E: Monitoring and Evaluation

What is the main difference between SOAP and ADIME?

SOAP organizes general healthcare documentation as Subjective, Objective, Assessment, and Plan, while ADIME follows the Nutrition Care Process: Assessment, Diagnosis, Intervention, and Monitoring/Evaluation

While SOAP is a universal healthcare charting method that organizes data by information type (subjective, objective, assessment, plan), ADIME is a specialized nutrition framework that follows the registered dietitian's sequential workflow (assessment, nutrition diagnosis, intervention, monitoring, and evaluation)

What does IER stand for?

Intervention, Evaluation, and Revision of care

What do FOCUS notes document?

Data, action, and response

What does PIE stand for?

Problem, Intervention, and Evaluation

What is CBE?

Charting by exception — documenting only unusual events