Formats of Nutrition Progress Notes in Electronic Health Records

As Electronic Health Records become more prevalent, there are many varying formats for nutrition care documentation.  When a healthcare organization makes a decision to purchase or create an electronic health record, part of that implementation process is to determine the format of the E.H.R.  Generally there are a number of templates to choose from, but customization to the individual organization is usually part of the implementation process.  

Templates for both "views" as well as capturing data are customized by profession as well as by organization.  For example, when a nurse logs into the health record the data that they will likely use will be included in their initial data view, the same for a physician view or a dietitian view.  Templates can also have some data automatically populated (e.g. patient identification data, heights, weights, medical problem list) and can offer options from a drop-down menu (e.g. nutrition diagnosis, nutrition interventions).  The data contained in a nutrition care note can be organized in many different ways.  Sometimes it is organized in an ADIME or SOAP format with headings for each major category, but often it is organized differently.

As institutions develop templates and establish local documentation standards, in the United States, institutions also consult recommendations from accreditation organizations such as the Joint Commission.  The official "do not use list" of abbreviations identifies abbreviations that can lead to confusion due to similarities to other abbreviations.  

In the example used in this case, the healthcare organization has chosen to organize the data in the following order to emphasize the information that is most important to be shared with other healthcare professionals at the top and other supporting information later.  Items in blue below are autopopulated - either as headings in the template or from other information already included in other sections of the E.H.R.

The following sections were identified and content described below.