DOCUMENTATION OF NCP

Inggita Kusumastuty, S.Gz, M.Biomed

Medical Record

Is a systematic documentation of a patients medical history and care Used both for the physical document and the body of information that comprises the persons health history Intensely personal documents; many issues around access, storage, and disposal

Nutritional Care Record

Written documentation of the nutritional care process, including the interventions and activities used to meet the nutritional objectives If its not documented, it didnt happen. Medical record is a legal document.

Catatan Asuhan Gizi

Pendokumentasian NCP menguntungkan : Menjamin asuhan gizi lebih relevan, lengkap dan efektif oleh karena didasarkan atas problem Memberikan kesempatan tim kesehatan yang lain memahami masalah dan intervensinya Memberikan kesempatan tim yang lain berpartisipasi dalam proses intervensi.

Documentation Styles

ADIME (assessment, diagnosis, intervention, monitoring and evaluation) DAP (diagnosis, assessment, plan) DAR (data, action, response) PIE (problem, intervention, evaluation) PES (problem, etiology, symptoms) IER (intervention, evaluation, revision) HOAP (history, observation, assessment, plan) SAP (screen, assess, plan) SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions) SOAP (subjective, objective, assessment, plan)
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Chart Note

S = Subjective O = Objective A = Assessment P = Plan

Dx = Plan for additional diagnosis or assessment RX = Plan for treatment PtEd = Plan for patient education

SOAP Notes
S: Subjective Info provided by patient, family, or other Pertinent socioeconomic, cultural info Level of physical activity Significant nutritional history: usual eating pattern, cooking, dining out Work schedule
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SOAP Notescontd
O: Objective Factual, reproducible observations Diagnosis Height, age, weightand weight gain/loss patterns Lab data Clinical data (nausea, diarrhea) Diet order Medications Estimation of nutritional needs
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SOAP Notescontd
A: Assessment Nutrition diagnosis Interpretation of patients status based on subjective and objective info Evaluation of nutritional history Assessment of laboratory data and medications Assessment of diet order Assessment of patients comprehension and motivation

SOAP Notescontd
P: Plan Diagnostic studies needed Further workup, data needed Medical nutrition therapy goals Education plans Recommendations for nutritional care

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ADIME
Developed to facilitate the NCP A Assessment D Diagnosis I Intervention M Monitoring E - Evaluation

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PAPER FORM VS ELECTRONIC MEDICAL RECORD

PAPER FORM

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ELECTRONIC MEDICAL RECORD

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EXAMPLE : CHARTING NUTRITION ASSESSMENT (Mercy Medical Center Meditech)

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Mercy Medical Center Meditech Charting: Nutrition Assessment

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Mercy Medical Center Initial Assessment (cont)

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Mercy Medical Center Initial Assessment (cont)

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Mercy Medical Center Meditech Charting: Nutrition Assessment

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Mercy Medical Center Meditech Charting Reassessment

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Mercy Medical Center Meditech Charting Reassessment

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THANKS FOR JOIN THIS CLASS

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