RD Documentation in an IPC Environment

Scenario

Currently our hospital is in the process of developing assessment forms for the new electronic documentation system. The goal is to have one (large) assessment form for all allied health professionals, each profession having their own designated area. Instead of repeating assessment information such as past medical history, medications, etc., health professions will have check boxes indicating they have reviewed information. Would this meet charting guidelines for RDs or do we need to include spaces in the nutrition care section for this information?

Generally, there is no need to repeat information that exists in the chart elsewhere when conducting nutrition assessments or follow-up care. Repeating information is not a very efficient use of an RD’s time and may also risk transcription errors for medication doses, lab values, etc. However, when RDs refer to relevant information elsewhere, such as past medical history or medications, they must comment on the significant information they relied upon in their own nutrition care planning and monitoring notes.

It is also important to use professional judgment when relying on documentation made by other team members. For example, if the weight documented for a patient seems too low or too high, an RD may wish to have the weight re-done for verification. A weight discrepancy might indicate an error in the weight transcription or perhaps that the scale needs to be serviced or calibrated.

Organizations have different systems and elements to document nutrition care effectively. Some have a specific documentation style or culture that RDs should follow. Others have specific policies that outline documentation methods such as charting by exception and charting by reference. Regardless of the system or method chosen, the documentation should provide a clear picture of the nutrition assessment, planning, intervention and evaluation that have occurred in caring for a client.

RDs need to ask themselves “If anyone were to ever review my documentation, would the information clearly tell the story about the client’s nutrition care?” 

COLLEGE RESOURCES

College of Dietitians of Ontario. Record Keeping Guidelines for Registered Dietitians in Ontario.

 Richard Steinecke, LL.B. and CDO, Jurisprudence Handbook for Dietitians in Ontario, Chapter 8, “Record Keeping”.