Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners

Objective To compare documentation of two groups of clinical nutrition practitioners for evidence of the nutrition care process. Design This study used a comparative descriptive design. A retrospective chart review was conducted on all nutrition documentation in closed patient records. Documentation of two groups of nutrition practitioners (institution A=practitioners who received initial orientation and routine reinforcement in use of nutrition care process standards; institution B=practitioners who received orientation in use of a further assessment and medical nutrition therapy intervention procedure) was compared for evidence of a six-step nutrition care process. Sample/setting The sample consisted of randomly selected patient records (N=60). A total of 15 oncology and 15 chronic renal failure patient records from each of two Midwestern tertiary-care hospitals were reviewed. Main outcome measures Outcome measures were number of nutrition care process steps documented, appropriate relationships among documented steps in the nutrition care process, and the number of complete, incomplete, and interrupted chains. Statistical analyses Two-sample t tests and chi(2) analyses were used. Results Nutrition practitioners at institution A documented approximately three times as many nutrition care process steps per patient per chain that demonstrated appropriate relationships as did nutrition practitioners at institution B (2.69 +/- 1.15 and 0.80 +/- 0.62, respectively [mean +/- standard deviation]) (P <.001). There were no outcome, judgments related to goals documented in chains at either institution and because of this there were no completed nutrition care process chains at either institution. Conclusions Nutrition practitioners with orientation to nutrition care process standards documented more related nutrition care process steps than practitioners without this orientation. Providing nutrition practitioners with ongoing education and clinical experiences in use and documentation of the nutrition care process and a standardized language may be indicated to increase the number of completed nutrition care process chains and improve documentation of nutrition care and patient outcomes.