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Dietetic documentation: Content, language and the meaning of standardization in Swedish dietitians’ patient record notes
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics.
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 [en]
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: urn:nbn:se:uu:diva-263915ISBN: 978-91-554-9359-2 (print)OAI: oai:DiVA.org:uu-263915DiVA: diva2:858722
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
List of papers
1. Evaluation of a Nutrition Care Process-based audit instrument, the Diet-NCP-Audit, for documentation of dietetic care in medical records
Open this publication in new window or tab >>Evaluation of a Nutrition Care Process-based audit instrument, the Diet-NCP-Audit, for documentation of dietetic care in medical records
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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.

Keyword
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:nbn:se:uu:diva-200517 (URN)10.1111/scs.12049 (DOI)000334503400021 ()
Available from: 2013-05-29 Created: 2013-05-29 Last updated: 2017-12-06Bibliographically approved
2. Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement
Open this publication in new window or tab >>Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement
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2015 (English)In: Nutrition & Dietetics, ISSN 1446-6368, E-ISSN 1747-0080, Vol. 72, no 1, 74-80 p.Article in journal (Refereed) Published
Abstract [en]

Aim

High-quality documentation in patient records is essential for patient safety and plays a prominent role in the delivery and evaluation of dietetic/nutrition care. We aimed to evaluate dietitians' documentation in patient records according to the four steps in the Nutrition Care Process: assessment, diagnosis, intervention and monitoring/evaluation.

Methods

A retrospective audit of 147 systematically collected outpatient dietetic notes from primary care centres and hospitals in central Sweden was performed using a validated audit instrument. The instrument was used to assess the documentation of 14 items: 10 items focusing on the Nutrition Care Process steps and four items on language clarity and structure, with a maximum total score of 26 for each dietetic note. The notes were divided into three different quality levels, A (high score), B (medium score) or C (low score). Comparisons were made between notes from primary care and hospitals.

Results

The audit showed that the majority of the notes were placed at level B, scoring 13.5–19.5. Only 3% of the notes scored higher than 19.5. The most frequently documented items were intervention (90%), evaluation (70%) and nutrition problem (56%), whereas the least documented items were nutrition prescription (15%), goal of intervention (9%) and connection of problem-etiology-symptom (5%). Flaws in lingual clarity were common (72%). Primary care notes received higher scores than those from hospitals.

Conclusions

The audit shows that Swedish dietetic documentation needs to be improved, for example, by further training and education in the Nutrition Care Process and its standardised terminology.

National Category
Other Social Sciences Nutrition and Dietetics
Research subject
Food, Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-230205 (URN)10.1111/1747-0080.12128 (DOI)000352153400012 ()
Available from: 2014-08-20 Created: 2014-08-20 Last updated: 2017-12-05Bibliographically approved
3. The power of language on patient‐centredness: linguistic devices in the dietetic notes of patient records
Open this publication in new window or tab >>The power of language on patient‐centredness: linguistic devices in the dietetic notes of patient records
2015 (English)In: International Journal of Applied Linguistics, ISSN 0802-6106, E-ISSN 1473-4192, Vol. 25, no 2, 225-245 p.Article in journal (Refereed) Published
Abstract [en]

n this paper, 30 notes written by Swedish dietitians in patient records are analysed, inspired by Critical Linguistics and Critical Discourse Analysis. Focusing on linguistic devices such as agency sources and evidential markers, we describe how patients are constantly referred to only in terms of the institutional patient role, or not referred to at all, through different techniques such as nominalization and passive verbs. The dietitians writing the notes are even more absent from the text, as they almost never refer to themselves as persons in the dietetic notes. There is a stated ambition in health care to provide patient-centred care and a collaborative patient-clinician relationship. However, we suggest that there might be a need for more person-centred language in dietetics.

Keyword
Patient records, dietetics, medical discourse, patient-centered care
National Category
Other Social Sciences General Language Studies and Linguistics
Research subject
Food, Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-230206 (URN)10.1111/ijal.12064 (DOI)000368177400005 ()
Available from: 2014-08-20 Created: 2014-08-20 Last updated: 2017-12-05Bibliographically approved
4. The struggle to balance system and lifeworld: Swedish dietitians’ experiences of a standardised nutrition care process and terminology
Open this publication in new window or tab >>The struggle to balance system and lifeworld: Swedish dietitians’ experiences of a standardised nutrition care process and terminology
2016 (English)In: Health Sociology Review, ISSN 1446-1242, E-ISSN 1839-3551, Vol. 25, no 3, 240-255 p.Article in journal (Refereed) Published
Abstract [en]

In this study, we explored Swedish dietitians’ experiences of a standardised Nutrition Care Process (NCP) and terminology from the perspective of Habermas’ concepts of system and lifeworld. Seven focus group discussions were analysed thematically. In thispaper, we argue that dietitians seem to mainly connect the NCP with a system perspective, highlighting aspects such as professionalism, measurability and clarity of the patient record as helpful outcomes from the NCP standardisation. We also see a tension between system and lifeworld, as dietitians emphasised the importance of the dietitian–patient relationship, stating that a patient’s complex situation does not always fit into the pre-defined NCP terms and measurements. Several approaches were identified whereby dietitians tried to reach a balance between the system and lifeworld. We argue that strategies for achieving this balance need more attention in the education and implementation of standardised care processes and terminologies.

Keyword
Nutrition Care Process; dietitian; professionalism; terminology; Habermas
National Category
Other Social Sciences not elsewhere specified Nutrition and Dietetics
Research subject
Food, Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-263914 (URN)10.1080/14461242.2016.1197783 (DOI)000384077900002 ()
Available from: 2015-10-04 Created: 2015-10-04 Last updated: 2017-12-01Bibliographically approved

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