Physicians prefer goal-oriented note format more than three to one over other outcome-focused documentation.
To assess preference for outcome-focused nutrition notes, two note formats were selected from the literature and tested against a modified, goal-oriented format. Focus charting and intervention, evaluation, and revision (IER) formats were compared with a charting-by-exception style that was modified to include goals and reassessment of risk. Notes were handwritten in each format and contained the same information. Physicians were asked to choose their preference and explain why that format was selected. Initially, focus charting was tested against the goal-oriented format. The more popular of the two was then tested against the IER format. Nineteen physicians were surveyed by a registered dietitian for each comparison. Physicians preferred the goal-oriented format over focus charting and IER formats 9:1 and 3:1, respectively. In the first survey, physicians preferred the goal-oriented format because the plan was clearly stated, thereby rendering the note easier to understand. The goal-oriented format was preferred in the second survey because the note was considered to be concise and easy to read and contained expected outcomes. Physicians want short communication that includes easily identifiable goals and plans. We recommend that experienced dietitians use the goal-oriented format developed for this study, and preferred by physicians, for follow-up nutrition notes.
Klein
C J
CJ
Division of Critical Care Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Md. 21201-1595, USA.
Bosworth
J B
JB
Wiles
C E
CE
D001291:Attitude of Health Personnel; D003625:Data Collection; D004282:Documentation / Q000379:methods*; D005069:Evaluation Studies as Topic; D006040:Goals; D006801:Humans; D009747:Nutritional Physiological Phenomena; D010347:Patient Care Planning; D010820:Physicians / Q000523:psychology*