Impact of Nutrition Care Process Documentation in Obese Children and Adolescents with Metabolic Syndrome and/or Non-Alcoholic Fatty Liver Disease.

Gadah Mujlli,Dara Aldisi,Mahmoud M A Abulmeaty,Ghadeer S Aljuraiban

doi:10.3390/healthcare9020188

Abstract

This study evaluated the Nutrition Care Process documentation used by dietitians for obese pediatric patients diagnosed with metabolic syndrome (MetS) and/or non-alcoholic fatty liver disease (NAFLD) and its impact on the achievement of nutritional goals. This retrospective cohort study utilized data retrieved from three tertiary care hospitals in Riyadh. A total of 142 obese pediatric patients aged 8–18 years diagnosed with NAFLD and/or MetS were evaluated. Data on weight, height, blood pressure (BP), lipid profile, and liver enzymes were collected. A validated audit was used to assess the documentation quality. Twenty-seven (46.6%) dietitian notes received a high score, 21 (36.2%) received a medium score, and 10 (17.2%) received a low score. There was no significant effect of dietitian audit scores on nutritional outcomes, however, the change in body mass index from 6 to 12 months follow-up period was inversely correlated with the audit score (r = −0.761, p = 0.007), and alkaline phosphatase was inversely correlated with the audit score (r = −0.819, p = 0.013). In conclusion, there was a clear variation in the quality of dietitians’ documentation and the impact of documentation scores on nutritional outcomes.

Highlights

Improving the quality of documentation in healthcare settings has been an ongoing process in various healthcare professions
This study indicated that there was a severe lack of dietitian documentation among the study population, which is critical for nutritional interventions because obesity, non-alcoholic fatty liver disease (NAFLD), and metabolic syndrome (MetS) are first tackled through nutritional interventions
The audit tool utilized for assessing the level of dietitian documentation was designed utilizing the Nutrition Care Process (NCP), which was recently implemented in Saudi hospitals

Summary

Introduction

Improving the quality of documentation in healthcare settings has been an ongoing process in various healthcare professions This need arose from the increasing rate of preventable medical errors that result from poor quality documentation [1]. The Academy of Nutrition and Dietetics (eatright.org) defines the NCP as “a systematic problem-solving method that dietetic professionals use to critically think and make decisions to address nutrition-related problems and provide safe and effective quality nutrition care” [5]. It consists of four interrelated concepts and steps: nutrition assessment, diagnosis, intervention, and monitoring and evaluation. After developing the NCP, the Academy of Nutrition and Dietetics developed a new format for dietitian documentation to document the NCP steps; this new format is abbreviated ADIME [6]

Results

Discussion

Conclusion