Automating clinical dietetics documentation.

Abstract

A review of commonly used charting formats discussed in the dietetics literature revealed that the subjective, objective assessment and planning (SOAP) approach is most frequently used by dietitians. Formats reported in the nursing literature were charting by exception (CBE); problem, intervention, evaluation (PIE); and focus/data, action, response (Focus/DAR). The strengths and weaknesses of the charting styles as they apply to the needs of clinical dietetic specialists were reviewed. We then decided to test in house the Focus/DAR format by assessing chart entries for adherence to style, brevity, and physician response. Dietitians pilot tested all the methods, but found them time consuming to use. The consensus was that SOAP could be adapted to the documentation needs of the individual situation and required little additional staff training. Often because of time limitations, a narrative summary was most appropriate. Chart entry length was reduced as much as 200% when staff were given brief clinical communication as a goal, and a further reduction when line limits were imposed. The physician response was positive, with recommendations followed in 50% of charts, compared with 34% in a previous audit. A nutrition documentation system was developed by the researchers by reviewing medical chart structure, documentation standards, methods of risk identification, and terminology for clinical documentation style. The resulting system affected the decision making of physicians, who could now scan notes more quickly and implement nutrition recommendations in a more timely fashion.