Notes on Nutrition Informatics and Documentation

Nutrition Informatics

• Definition: 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.

• Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII):

  • A web-based system for collecting health outcomes data.
  • Available free to Academy members and RDNs and NDTRs via the Commission on Dietetic Registration.
  • Collects only de-identified nutrition diagnoses & follow-up data.

Electronic Clinical Quality Measure and Terminology

• eCQM Reporting:

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

• Challenges:

  • Need for standardized terminology for machine recognition.
  • Risk of data loss and challenges with interoperability.

Documentation of the Nutrition Care Process

• Purpose of Documentation:
  • Systematic recording of care and communication among healthcare team members.
  • Aiding in continuous quality improvement and legal documentation.
  • Use of CPT codes for billing and adherence to prospective payment systems.

Medical Record Charting Purposes

• Legal documentation of client care.
• Enhance communication among health care team members.
• Evaluate the effectiveness of the medical care provided.
• Manage funding and resources effectively.
• Facilitate third-party reimbursement and accreditation.

Joint Commission Official “Do Not Use” List

• Common Errors in Documentation:
  • "U" for unit: Likely to be misinterpreted. Replace with "unit".
  • "I U" for International Unit: Risk of confusion with IV or number 10.
  • Abbreviations like Q.D. and Q.O.D.: Potential for misunderstanding, recommended to use full terms such as "daily" and "every other day".
  • Trailing zeros in dosages: Can lead to decimal point confusion.

Nutrition Documentation Formats

• SOAP:

  • Subjective data, Objective data, Assessment, Plan.

• PES:

  • Nutrition Diagnosis: Problem, Etiology, Signs/Symptoms.

• ADIME:

  • Assessment, Diagnosis, Intervention, Monitoring & Evaluation.

• PIE:

  • Problem, Intervention, Evaluation.

• Charting by Exception (CBE):

  • Record only significant or unusual events.

Personal Medical Notebook

• Create a personalized system for notes.
• Confidentiality is essential.

Charting Guidelines

• Key principles of effective charting:
  • Document significant observations, sign notes, be timely.
  • Avoid charting for others and do not document procedures before they are completed.
  • Use clear language and avoid abbreviations unless they are widely understood.

Confidentiality

• HIPAA (1996):
  • Protects client information obtained through examination and treatment processes.

Key Takeaways

• Emphasize accurate and timely documentation.
• Familiarize yourself with the Joint Commission’s “Do Not Use” list to avoid common errors in documentation.
• Understand the various documentation formats and their specific purposes in nutrition care.