Evaluation of Dietetic Care Notes on the Documentation Quality and NCP Chain Linkages

Shahrir, Fatin Nabila (2022) Evaluation of Dietetic Care Notes on the Documentation Quality and NCP Chain Linkages. [Project Paper] (Submitted)

Text FPSK6 2022 12.pdf Download (1MB)

Abstract

The Nutrition Care Process (NCP) is a structured method of nutrition care provision used by dietitians in documenting their dietetic care note (DCN). A dietitian’s work involves the continuity and coordination of care and this involves other healthcare providers that will refer to the DCNs. Good communication of a patient’s data in the DCN is important to ensure that health care professionals receive the correct information needed. Hence, the quality of documentation of a dietetic care note is important. The quality of documentation can be evaluated by using an NCP audit tool. Previous study found that the quality of NCP documentation in Malaysia is of medium quality. However, a more recent study in the USA found that most of the NCP documentations are of high quality. DCNs from 94 different cases were audited with the objective to identify the level of quality of DCNs and the presence of NCP chains. An NCP audit tool called the NCP-QUEST was used to evaluate the DCNs. A majority of the DCNs are of medium quality level (64.8%). It was found that dietitians in the HPUPM dietetics clinic are able to document the relevant data and use standardised terminology for problem statement. However, the absence of certain elements in all or nearly all DCNs shows that dietitians in HPUPM have yet to implement the etiology category matrix, standardized Nutrition Intervention terminology, and goal progress. Most of the NCP chain links are present in most of the cases, with the most frequently documented NCP-Chain Link being the diagnosis-etiology link and etiology-intervention link. Therefore, there are more improvements that can be done in the NCP documentation, and more studies need to be done on associated factors

Item Type:	Project Paper
Faculty:	Faculty of Medicine and Health Science
Depositing User:	Mr Khoirul Asrimi Md Nor
Date Deposited:	16 Aug 2023 01:08
Last Modified:	16 Aug 2023 01:08
URI:	http://psaspb.upm.edu.my/id/eprint/972

Actions (login required)

View Item