Computer-Integrated Charting for Clinical Nutrition Services.

Abstract

The objective of this project was to automate clinical nutrition documentation, and integrate as such into the organization-wide computer-based system. Using the department's pre-printed forms for charting as its foundation, the data base was built from existing practice guidelines and approved standards of care. After extensive testing, re-building and integration testing, employee training was initiated and was extended throughout all phases of the data base conversion. The greatest impact on patient care has been the ability to readily access patient information via the data repository. Such data collected or recorded from either prior admissions or through outpatient therapies can be easily retrieved by any authorized professional throughout the health care system. No longer does the clinician scramble to find a height, weight, lab result or previous diet order; it can be located through only a few simple keystrokes! Other positive aspects of the computer integration have been the total coordination of patient orders, the capability for work assignment, the standardization of documentation and chart forms, the ability to place a charge for care given at the point of service, and the accurate monitoring of quality improvement data and productivity statistics. Changing practice never comes without its share of challenges. Probably the most difficult aspects have been the limited availability of hardware, training issues, and some inefficiency in work patterns; e.g. since not all departments are presently integrated, a permanent medical record is also being maintained which has resulted in some re-work and duplication of efforts. Once these other departments become fully integrated, the benefits will definitely outweigh the drawbacks. Computer technology continues to change the face of dietetics;. practitioners and clinical managers must keep apace with it!