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Evaluating Documentation of Dietetic Care in Swedish Medical Records
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics.
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics.
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. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
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2013 (English)In: MEDINFO 2013: Proceedings of the 14Th World Congress On Medical and Health Informatics, Pts 1 And 2 / [ed] Lehmann, CU; Ammenwerth, E and Nohr, C, 2013, 1078-1078 p.Conference paper, Published paper (Refereed)
Abstract [en]

An adequate documentation in medical records is essential for patient safety and high quality care. The aim of this study was to evaluate documentation by dietitians in Swedish medical records. A retrospective audit of 147 dietetic notes in electronic medical records was performed. The audit focused at documentation of essential parts of the dietetic care, as well as other quality aspects such as lingual clarity and structure of the documentation. The nutrition intervention showed to be the most documented part of dietetic care. However, the audit showed that several important parts of nutrition care were poorly documented, for instance nearly half of the audited records had no clear nutrition problem documented, and in most of the records, the goal of nutrition intervention was missing. The study shows that Swedish dietitians need to improve documentation in medical records, as a suggestion by implementing a more structured documentation model.

Place, publisher, year, edition, pages
2013. 1078-1078 p.
Series
Studies in Health Technology and Informatics, ISSN 0926-9630 ; 192
Keyword [en]
Medical records, audit, dietetics, documentation
National Category
Nutrition and Dietetics
Identifiers
URN: urn:nbn:se:uu:diva-233373DOI: 10.3233/978-1-61499-289-9-1078ISI: 000341021700346PubMedID: 23920852ISBN: 978-1-61499-289-9 (print)ISBN: 978-1-61499-288-2 (print)OAI: oai:DiVA.org:uu-233373DiVA: diva2:752047
Conference
14th World Congress on Medical and Health Informatics (MEDINFO), AUG 20-23, 2013, Copenhagen, DENMARK
Available from: 2014-10-02 Created: 2014-10-02 Last updated: 2014-10-02Bibliographically approved

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Lövestam, ElinKoochek, AfsanehKarlström, BritaAndersson, Agneta

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