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.
Article info
Publication history
Published online: November 01, 2019
Footnotes
STATEMENT OF POTENTIAL CONFLICT OF INTEREST A. Curry has employee stock options in Nuance Communications. C. Papoutsakis is an employee of the Academy of Nutrition and Dietetics, which has a financial interest in the Nutrition Care Process Terminology (NCPT) described here. A. Wootton is an employee of MatrixCare. No potential conflict of interest was reported by the remaining authors.
FUNDING/SUPPORT No funding support was received for this article.
Identification
Copyright
© 2020 the Academy of Nutrition and Dietetics, American Society for Parenteral and Enteral Nutrition, and Association of Clinical Documentation Improvement Specialists. Published by Elsevier Inc. All rights reserved.
