Documentation of nutritional care
1980
Ometer, Jane Lynne
Although auditing of medical record nutritional entries to evaluate the quality of nutritional care has developed with the expansion of Professional Standards Review Organizations (PSROs), there is little data about the charting practices of dietitians. A survey with 325 respondents from 92 facilities showed that about half of the dietary departments and individual facilities required charting of specific information and had nutritional audit criteria. Those who recorded charts of virtually all patients on modified diets also recorded more charts of regular diet patients. When patient load was 100 or less, there was a significant increase in the frequency of charting. About half the respondents felt that the amount of charting they did was adequate. Lack of time and availability of charts, patients loads and staffing patterns, and pressure of other duties were identified as the factors that decreased recording.
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