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Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care

Published:November 01, 2019DOI:https://doi.org/10.1016/j.jand.2019.07.018

      Abstract

      Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals—nurses, physicians, advanced practice providers, pharmacists, and dietitians—identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization’s Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.
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      Biography

      C. E. Kight is a clinical nutrition specialist, UW Health–University of Wisconsin Hospitals and Clinics, Madison, WI.

      Biography

      J. M. Bouche is a nutrition support dietitian, Option Care, Wauwatosa, WI.

      Biography

      A. Curry is a senior consultant and client services manager, Healthcare Division, Nuance Communications, Burlington, MA.

      Biography

      D. Frankenfield is a manager and nutrition support dietitian, Penn State Health, Hershey, PA.

      Biography

      D. Wilk is a manager, clinical documentation improvement, Penn State Health, Hershey, PA.

      Biography

      K. Good is a manager, education services, Enjoin, Collierville, TN.

      Biography

      P. Guenter is senior director of clinical practice, quality, and advocacy, American Society for Parenteral and Enteral Nutrition, Silver Spring, MD.

      Biography

      B. Murphy is director, Association of Clinical Documentation Improvement Specialists, Middleton, MA.

      Biography

      C. Papoutsakis is senior director, Data Science Center, Academy of Nutrition and Dietetics, Chicago, IL.

      Biography

      E. Brown Richards is a clinical dietitian, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY.

      Biography

      V. W. Vanek is regional medical informatics officer, Mercy Health Youngstown Region, Youngstown, OH.

      Biography

      A. Wootton is director of nutrition management, MatrixCare, Bloomington, MN.