CONCEPT DOCUMENTATION NUTRITIONAL CARE
Individual/Population Interacts with Nutrition Professional
a. Nutrition Assessment and Re-Assessment
1. Obtain or collect relevant data
2. Analyze or interpretation of collected data
b. Nutrition Diagnosis
1. P: Identify the Problem
2. E: Determine the Etiology or cause
3. S: Signs and symptoms
c. Nutrition Intervention
1. Define interventions and prescriptions
2. Formulate goals and determine actions
3. Implementing action
d. Nutrition Monitoring and Evaluation
1. Selects or identifies quality indicators
2. Monitor and evaluate diagnosis completion
Definition of documentation
• Process of collecting, selecting, processing, and storage of information in the field of
knowledge
• the provision or collection of evidence from information such as pictures, quotations,
newspaper, cuttings newspapers, and other reference materials
Purpose of documentation
• Means of communication
• As a responsibility
• For statistical information
• Education
• Source of research data
• Service quality assurance
• Source of data for sustainable nutrition care services
• As a provider of data / patient history for further treatment from other health teams
, • Allows patients to make decisions about treatment to be given
• Provides a record of diagnosis and treatment
• As quality assurance
• Communication
a. Health care team
b. Evidence of services provided
c. Evidence for accreditation
d. State audit
Documentation requirements
• Documentation is complete, clear, concise, objective, can be accountable and accurate
• Notes: date, time, and service provider
• No need for complete sentences but pronunciation must be correct
• Avoid abbreviations that are unclear or have multiple meanings
• Official word abbreviations are recorded in the abbreviation list
• Avoid opinions, comments, criticism or debate between team members
• Documentation in accordance with service time
• At the end of the note: signature, profession, and name
• Cannot be delegated
Various forms of documentation
1. DAP (Diagnosis, Assessment, Plan)
2. DART (Data, Action, Response, Treatment)
3. PIE (Problem, Intervention, Evaluation)
4. PES (Problem, Etiology, Symptoms)
5. IER (Intervention, Evaluation, Revision)
6. HOAP (History, Observation, Assessment, Plan)
7. SAP (Screen, Assess, Plan)
8. SOAP (Subjective, Objective, Assessment, Plan)
a) Subjective
• Information extracted from the patient, family or person closest to the patient
• Complaints perceived by the patient
• Data regarding social and cultural psychology
Individual/Population Interacts with Nutrition Professional
a. Nutrition Assessment and Re-Assessment
1. Obtain or collect relevant data
2. Analyze or interpretation of collected data
b. Nutrition Diagnosis
1. P: Identify the Problem
2. E: Determine the Etiology or cause
3. S: Signs and symptoms
c. Nutrition Intervention
1. Define interventions and prescriptions
2. Formulate goals and determine actions
3. Implementing action
d. Nutrition Monitoring and Evaluation
1. Selects or identifies quality indicators
2. Monitor and evaluate diagnosis completion
Definition of documentation
• Process of collecting, selecting, processing, and storage of information in the field of
knowledge
• the provision or collection of evidence from information such as pictures, quotations,
newspaper, cuttings newspapers, and other reference materials
Purpose of documentation
• Means of communication
• As a responsibility
• For statistical information
• Education
• Source of research data
• Service quality assurance
• Source of data for sustainable nutrition care services
• As a provider of data / patient history for further treatment from other health teams
, • Allows patients to make decisions about treatment to be given
• Provides a record of diagnosis and treatment
• As quality assurance
• Communication
a. Health care team
b. Evidence of services provided
c. Evidence for accreditation
d. State audit
Documentation requirements
• Documentation is complete, clear, concise, objective, can be accountable and accurate
• Notes: date, time, and service provider
• No need for complete sentences but pronunciation must be correct
• Avoid abbreviations that are unclear or have multiple meanings
• Official word abbreviations are recorded in the abbreviation list
• Avoid opinions, comments, criticism or debate between team members
• Documentation in accordance with service time
• At the end of the note: signature, profession, and name
• Cannot be delegated
Various forms of documentation
1. DAP (Diagnosis, Assessment, Plan)
2. DART (Data, Action, Response, Treatment)
3. PIE (Problem, Intervention, Evaluation)
4. PES (Problem, Etiology, Symptoms)
5. IER (Intervention, Evaluation, Revision)
6. HOAP (History, Observation, Assessment, Plan)
7. SAP (Screen, Assess, Plan)
8. SOAP (Subjective, Objective, Assessment, Plan)
a) Subjective
• Information extracted from the patient, family or person closest to the patient
• Complaints perceived by the patient
• Data regarding social and cultural psychology
