Evaluating documentation of dietetic care in Swedish medical records.
An adequate documentation in medical records is essential for patient safety and high quality care. The aim of this study was to evaluate documentation by dietitians in Swedish medical records. A retrospective audit of147 dietetic notes in electronic medical records was performed. The audit focused at documentation of essential parts of the dietetic care, as well as other quality aspects such as lingual clarity and structure of the documentation. The nutrition intervention showed to be the most documented part of dietetic care. However, the audit showed that several important parts of nutrition care were poorly documented, for instance nearly half of the audited records had no clear nutrition problem documented, and in most of the records, the goal of nutrition intervention was missing. The study shows that Swedish dietitians need to improve documentation in medical records, as a suggestion by implementing a more structured documentation model.
Department of Food, Nutrition and Dietetics, Uppsala University, Sweden.
Elin
E
Lövestam
Ylva
Y
Orrevall
Afsaneh
A
Koochek
Brita
B
Karlström
Agneta
A
Andersson
D015930:Diet Records; D004045:Dietary Services / Q000145:classification* / Q000592:standards*; D004282:Documentation / Q000145:classification / Q000592:standards; D062527:Meaningful Use / Q000145:classification / Q000592:standards*; D008485:Medical Audit; D016347:Medical Records Systems, Computerized / Q000145:classification* / Q000592:standards*; D064686:Nutritionists / Q000706:statistics & numerical data*; D013548:Sweden