A comparison of outcome focused documentation with soap notes for inpatient care at Saint Francis Medical Center, Peoria, IL

Abstract

Outcome Focused Documentation (OFD) was initiated eight months ago at Saint Francis Medical Center, a teaching hospital, to improve documentation focus on nutrition concerns and to increase physician response to dietitian recommendations. OFD incorporates a problem list format and charting by exception. Nutrition problems and concerns are clearly identified and focus on an action plan of treatment and patient outcome results through specific nutrition care interventions and recommendations. Following extensive staff training, implementation of OFD and ongoing medical record audits, a survey of inpatient dietitians was conducted. The survey found that 100% of the dietitians agreed that OFD clearly identifies nutrition problems and focuses on outcome results and actions better than SOAP format. To assess physician receptiveness to dietitian recommendations, medical records were reviewed to check for a physician order within 72 hours. Ninety-one notes in SOAP format were reviewed and found a 27% physician response to dietitian recommendations. A review of OFD indicated 74% of dieititan recommendations were implemented by physicians. OFD has significantly improved physician response to dietitian recommendations at Saint Francis Medical Center due to clearly identified patient nutrition problems and a better understanding of the nutrition intervention process among the health care team.