Notes on Nutrition Informatics and Documentation

Nutrition Informatics

The study and practice of collecting data to generate meaningful information and knowledge in nutrition.

HITECH Act (2009)

Focus on electronic data collection and retrieval in health care.

ANDHII

Academy of Nutrition and Dietetics Health Informatics Infrastructure, a web-based system for collecting health outcomes data.

eCQM Reporting

Institutions reimbursed by CMS must submit eCQM to report the quality of care.

Challenges in eCQM

Need for standardized terminology for machine recognition and risks of data loss and interoperability issues.

Purpose of Documentation

Systematic recording of care and communication among healthcare team members, aiding in quality improvement and legal documentation.

CPT Codes

Codes used for billing and adherence to prospective payment systems.

Medical Record Charting Purposes

Includes legal documentation of client care, enhancing communication, evaluating medical care effectiveness, managing funding, and facilitating reimbursement.

Joint Commission Official 'Do Not Use' List

Outlines common errors in documentation, such as using 'U' for unit and 'I U' for International Unit.

Documentation Formats: SOAP

Subjective data, Objective data, Assessment, Plan.

Documentation Formats: PES

Nutrition Diagnosis: Problem, Etiology, Signs/Symptoms.

Documentation Formats: ADIME

Assessment, Diagnosis, Intervention, Monitoring & Evaluation.

Documentation Formats: PIE

Problem, Intervention, Evaluation.

Documentation Formats: CBE

Charting by Exception, recording only significant or unusual events.

Personal Medical Notebook

Create a personalized system for notes with an emphasis on confidentiality.

Charting Guidelines

Key principles include documenting observations, signing notes, avoiding charting for others, and using clear language.

HIPAA (1996)

Protects client information obtained through examination and treatment processes.

Key Takeaways

Emphasize accurate and timely documentation, familiarize with 'Do Not Use' list, and understand documentation formats.