Does documentation in nursing records of nutritional screening on admission to hospital reflect the use of evidence-based practice guidelines for malnutrition?
OBJECTIVE
To describe the documentation of nutrition-related data and wards referral to dieticians in a Belgian university hospital.


METHODS
Retrospective analysis of 506 nursing records.


RESULTS
Body weight and height are documented in 22%. "Feeding assistance" and "usual food intake pattern" are documented in 68% of all cases, and in 71% it is marked whether the patient is on a diet. Eight percent of the patients are referred to a dietician, but the indications for these referrals are not clear.


CONCLUSIONS
Given the poor documentation, most likely these patients are not adequately screened for malnutrition as recommended.


CONCLUSIONS
Nurses' documentation of nutrition-related data should be improved to facilitate treatment of malnutrition with tailored multidisciplinary interventions.
Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
Bart
B
Geurden
Conny
C
Wouters
Erik
E
Franck
Joost
J
Weyler
Dirk
D
Ysebaert
D003430:Cross-Sectional Studies; D055318:Evidence-Based Nursing; D006801:Humans; D009737:Nursing Records; D015596:Nutrition Assessment; D010343:Patient Admission; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies
Evidence-based practice; malnutrition; nursing record