uu.seUppsala University Publications
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Evaluation of a Nutrition Care Process-based audit instrument, the Diet-NCP-Audit, for documentation of dietetic care in medical records
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics.
Karolinska Insitutet, Stockholm.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics.
Show others and affiliations
2014 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 28, no 2, 390-397 p.Article in journal (Refereed) Published
Abstract [en]

Adequate documentation in medical records is important for high-quality health care. Documentation quality is widely studied within nursing, but studies are lacking within dietetic care. The aim of this study was to translate, elaborate and evaluate an audit instrument, based on the four-step Nutrition Care Process model, for documentation of dietetic care in medical records. The audit instrument includes 14 items focused on essential parts of dietetic care and the documentation's clarity and structure. Each item is to be rated 0-1 or 0-2 points, with a maximum total instrument score of 26. A detailed manual was added to facilitate the interpretation and increase the reliability of the instrument. The instrument is based on a similar tool initiated 9 years ago in the United States, which in this study was translated to Swedish and further elaborated. The translated and further elaborated instrument was named Diet-NCP-Audit. Firstly, the content validity of the Diet-NCP-Audit instrument was tested by five experienced dietitians. They rated the relevance and clarity of the included items. After a first rating, minor improvements were made. After the second rating, the Content Validity Indexes were 1.0, and the Clarity Index was 0.98. Secondly, to test the reliability, four dietitians reviewed 20 systematically collected dietetic notes independently using the audit instrument. Before the review, a calibration process was performed. A comparison of the reviews was performed, which resulted in a moderate inter-rater agreement with Krippendorff's α = 0.65-0.67. Grouping the audit results in three levels: lower, medium or higher range, a Krippendorff's α of 0.74 was considered high reliability. Also, an intra-rater reliability test-retest with a 9 weeks interval, performed by one dietitian, showed strong agreement. To conclude, the evaluated audit instrument had high content validity and moderate to high reliability and can be used in auditing documentation of dietetic care.

Place, publisher, year, edition, pages
2014. Vol. 28, no 2, 390-397 p.
Keyword [en]
Dietetic, documentation, medical records, nutrition care process
National Category
Social Sciences Interdisciplinary Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Food, Nutrition and Dietetics
Identifiers
URN: urn:nbn:se:uu:diva-200517DOI: 10.1111/scs.12049ISI: 000334503400021OAI: oai:DiVA.org:uu-200517DiVA: diva2:623976
Available from: 2013-05-29 Created: 2013-05-29 Last updated: 2017-12-06Bibliographically approved
In thesis
1. Dietetic documentation: Content, language and the meaning of standardization in Swedish dietitians’ patient record notes
Open this publication in new window or tab >>Dietetic documentation: Content, language and the meaning of standardization in Swedish dietitians’ patient record notes
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of this thesis was to explore dietetic notes in Swedish patient records regarding content, language and the meaning of standardization.

Firstly, an audit instrument for dietetic notes in patient records, Diet-NCP-Audit, was elaborated and tested. The instrument, a 14-item scoring questionnaire based on the four steps of the Nutrition Care Process (NCP), proved to have high content validity and moderate to high inter- and intra-rater reliability. The instrument was then used in an evaluation of the content, language and structure of 147 Swedish dietetic notes. Although the nutrition intervention and some information about the evaluation were well documented, the overall result showed a need for improvement in several aspects of documentation, such as nutrition prescriptions, goals and the connection between problem-etiology-symptom.

After this, 30 of the audited dietetic notes were also included in a critical linguistic study exploring how the patients and dietitians were referred to in the notes. The dietetic notes contained several linguistic devices that impersonalized and passivized both the patient and the dietitian. Thus, the grammar of the dietetic notes did not enhance or reflect the patient-centered care and the active patient-caregiver relationship that is emphasized in most health care guidelines today.

Finally, a focus group study was performed. Swedish dietitians’ experiences of the standardized Nutrition Care Process (NCP) and its connected terminology (NCPT) were explored and analyzed from the perspective of Habermas’ system and lifeworld concepts. While recognizing many advantages with the NCP and NCPT, dietitians also expressed difficulties in combining the structured and standardized process and terminology with a flexible, patient-centered approach in nutrition care.

In summary, I argue that strategies for the improvement of dietetic documentation are needed. I also suggest that the NCP and NCPT play an essential role in dietetic professionalization. At the same time, however, this standardization may entail the risk of a reductionist view and difficulties regarding how to balance the different ideals of health care. Thus, there is a need for discussions concerning how to use and develop the NCP and dietetic language in a way that ensures the best possible care for the patient.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. 88 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Social Sciences, ISSN 1652-9030 ; 118
Keyword
Nutrition informatics, dietitians, Nutrition Care Process, patient records, professionalization
National Category
Other Social Sciences not elsewhere specified
Research subject
Food, Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-263915 (URN)978-91-554-9359-2 (ISBN)
Public defence
2015-11-20, BMC, sal A1: 111, Husargatan 3, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2015-10-30 Created: 2015-10-04 Last updated: 2015-11-10

Open Access in DiVA

No full text

Other links

Publisher's full text

Authority records BETA

Lövestam, ElinKoochek, AfsanehKarlström, BritaAndersson, Agneta

Search in DiVA

By author/editor
Lövestam, ElinKoochek, AfsanehKarlström, BritaAndersson, Agneta
By organisation
Department of Food, Nutrition and DieteticsClinical Nutrition and Metabolism
In the same journal
Scandinavian Journal of Caring Sciences
Social Sciences InterdisciplinaryHealth Care Service and Management, Health Policy and Services and Health Economy

Search outside of DiVA

GoogleGoogle Scholar

doi
urn-nbn

Altmetric score

doi
urn-nbn
Total: 932 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf