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Nutr Clin Pract. 2019 Nov 1. doi: 10.1002/ncp.10433. [Epub ahead of print]

Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care.

Author information

1
American Society for Parenteral and Enteral Nutrition.
2
Academy of Nutrition and Dietetics.
3
Association of Clinical Documentation Improvement Specialists.

Abstract

Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals-nurses, physicians, advanced practice providers, pharmacists, and dietitians-identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization's Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.

KEYWORDS:

electronic health records; malnutrition; nutrition assessment; nutrition care; nutrition screening

PMID:
31674077
DOI:
10.1002/ncp.10433

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