FROM THE ACADEMY Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care Cassandra E. Kight, PhD, RDN, CNSC; Jean M. Bouche, RD, CD, CNSC; Angie Curry, RN, CCDS; David Frankenfield, MS, RD; Katy Good, RN, CCDS, CCS; Peggi Guenter, PhD, RN, FAAN, FASPEN; Brian Murphy; Constantina Papoutsakis, PhD, RD; Emily Brown Richards, RD, CND, CNSC; Vincent W. Vanek, MD, FACS, FASPEN; Deanne Wilk, RN, CCDS, CCS; Amy Wootton, RDN; Academy of Nutrition and Dietetics; American Society for Parenteral and Enteral Nutrition; Association of Clinical Documentation Improvement Specialists ABSTRACT Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals—nurses, physicians, advanced practice providers, pharmacists, and dietitians—identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization’s Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recom- mendations can also serve as guidance for health care organizations choosing and implementing health care software. J Acad Nutr Diet. 2019;-(-):---. LECTRONIC HEALTH RECORDS tions (now referred to as The Joint malnutrition, and food insecurity; and (EHRs) offer access to patient Commission) for patient care with education and counseling for nutrition information locally, regionally, paper-based workflows.1 More and health issues. Health care costs in and nationally, and facilitate recently, the Academy of Nutrition the United States in 2017 were $3.5 E 5 coordination of care across health care and Dietetics (the Academy) published trillion. Diagnoses with nutrition settings. Health care clinicians who the Nutrition Care Process,2,3 which is therapy as an important component frequently provide direct patient care a systematic framework and language include obesity, with health care costs that influences nutrition care—nurses; to guide nutrition and dietetics practi- of $147 billion to $210 billion per year6; pharmacists; medical providers, tioners in documenting delivery of diabetes, with annual costs of $327 including physicians and advanced nutrition care. The American Society billion7; and gastrointestinal, liver, and practice providers; and dietitians—will for Parenteral and Enteral Nutrition pancreatic diseases, with an estimated be referred to here as nutrition clini- (ASPEN) developed Nutrition Care annual cost of $135.9 billion.8 The cians. Nutrition care of the patient in Pathways4 to provide the interprofes- direct medical costs for disease- the inpatient, ambulatory, or long-term sional nutrition clinician a framework associated malnutrition based on the health care setting commences with to guide nutrition care for pediatric National Health and Nutrition Exami- screening and assessment. Known or (Figure 1) and adult patients nation Survey, excluding institutional- suspected nutrition deficiencies or (Figure 2). The pathways illustrate rec- ized participants, were estimated to be problems are addressed with informa- ommended steps from screening $15.5 billion annually.9 The estimated tion from nutrition screening and through discharge from a health care costs of inpatient stays related to assessment. The first Nutrition Care setting with a focus on malnutrition. malnutrition accounted for nearly $49 Process flowchart was published in However, the provision of nutrition billion, or 12.6% of aggregate hospital 1994 to propose nutrition care indica- care for any nutrition condition in any costs, compared to $389.1 billion for all tors to the Joint Commission on health care setting follows the pathway non-maternal and non-neonatal Accreditation of Healthcare Organiza- steps: identification, assessment, inter- vention, monitoring, and discharge This article is being copublished by the planning. Academy of Nutrition and Dietetics, ª 2212-2672/Copyright 2019 the Academy Nutrition clinicians address inade- American Society for Parenteral and of Nutrition and Dietetics, American Society for Parenteral and Enteral Nutrition, and quate or excessive food intake; nutrient Enteral Nutrition, and Association of Association of Clinical Documentation deficiencies or nutrient excesses Clinical Documentation Improvement Improvement Specialists. Published by related to fluid, vitamins and/or min- Specialists. Minor differences in style may appear in each publication, but the article Elsevier Inc. All rights reserved. erals, alterations in gastrointestinal https://doi.org/10.1016/j.jand.2019.07.018 is substantially the same in each journal. function from the mouth to the colon, ª 2019 the Academy of Nutrition and Dietetics, American Society for Parenteral and Enteral Nutrition, and Association of Clinical Documentation Improvement Specialists. Published by Elsevier Inc. All rights reserved. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1 FROM THE ACADEMY A.S.P.E.N. PEDIATRIC NUTRITION CARE PATHWAY (Age 1 month – 18 years) AT RISK FOR MALNUTRITION/ MALNUTRITION PRESENT? ADMISSION YES NO Anthropometrics Obtained [MA, RN] Weight, Height/Length, Head Circumference and Mid-Upper NUTRITION CONSULT RESCREEN IN 4 DAYS Arm Circumference GENERATED [RD, RN] RD Notified (via EMR, automatic RISK FACTORS TO MONITOR trigger, documented in MR) WHILE HOSPITALIZED: NUTRITION SCREEN NPO/CLD >3 days [RN] Intake <50% for >3 days Admission screen completed within 24 Weight loss NUTRITION ASSESSMENT hours using validated tool Intubation [RD, NST] High risk disease or medical Results documented in Complete within one day of condition medical record. receiving consult Food and Nutrition History Anthropometrics Biochemical Data/Medical Tests & Procedures Nutrition Focused Physical Exam NO (NFPE) Client/Medical History MALNUTRITION PRESENT? YES DETERMINE MALNUTRITION SEVERITY [RD, NST] © 2015 American Society for Parenteral and Enteral Nutrition. All rights reserved. KEY DETERMINE CHRONICITY [RD] MA Medical Assistant Action Steps Acute <3 months Documentation Steps OT Occupational Therapist Chronic ≥3 months Communication Steps PT Physical Therapist RN Registered Nurse SLP Speech-Language Pathologist RD Registered Dietitian DETERMINE ETIOLOGY NPO/ CLD Nothing by NST Nutrition Support mouth/Clear Liquid Diet [RD, MD/NP/PA, RN, SW] Team EMR/MR Electronic MD Medical Doctor Medical Record or Medical • Medical Evaluation Record NP Nurse Practitioner Non-Illness Related (Social, Environmental, Behavioral) HC Head circumference PA Physician Assistant • Social (Evaluate Resources, Support, Stressors, R/O Neglect) PharmD Pharmacist MUAC Mid-upper arm circumference SW Social Worker WIC Women, Infants, and Children MORE ON NEXT PAGE Figure 1. American Society for Parenteral and Enteral Nutrition pediatric nutrition care pathway. (Reprinted with permission from ASPEN Copyright 2015.) 2 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2019 Volume - Number - FROM THE ACADEMY CONTINUED FROM PREVIOUS PAGE DOCUMENT MALNUTRITION CODE MALNUTRITION [RD, MD/NP/PA] Notify coder RD to document malnutrition severity, chronicity and supporting evidence Appropriate pediatric codes MD to document severity of malnutrition in progress note and add diagnosis to hospital problem list INTERVENTION MONITOR, EVALUATE & ATTEND MEDICAL ROUNDS [RD, RN, MD/NP/PA, SW, PharmD, PT, OT, SLP] [RD, RN, MD/NP/PA, SW, PharmD, PT, OT, SLP] Oral Nutrition and/or Vitamin/Mineral Supplements Daily Weights (<12 months old) or Daily to 2x/week Weights Medically & Developmentally Appropriate Diet (>12 months old) Nutrition Support (Enteral, Parenteral) Weekly Height/Length, HC (<2 years old), MUAC Education (Malnutrition, Increasing calories/protein) Biochemical Data/Medical Tests & Procedures Intake/Output Constipation, Diarrhea, Feeding problems, Infection, Gastrointestinal Tolerance Spasticity, Muscle weakness) Access Devices (feeding tubes, central venous access) Nutrition Focused Physical Exam (NFPE) NUTRITION REASSESSMENT [RD, NST] RE-EVALUATE CARE PLAN [MD/NP/PA, RD, RN, SW, PharmD, PT, OT, SLP] NUTRITION STATUS IMPROVING? Rule out Medical/Social Causes NO Feeding Evaluation Optimize Nutrition Intervention YES CONTINUE CURRENT PLAN/MONITOR [RD, RN, MD, NP/PA, SW, PharmD, PT, OT, SLP] © 2015 American Society for Parenteral and Enteral Nutrition. All rights reserved. PATIENT READY FOR DISCHARGE? NO KEY YES Action Steps MA Medical Assistant Documentation Steps OT Occupational Therapist PT Physical Therapist DISCHARGE PLAN Communication Steps RN Registered Nurse SLP Speech-Language [MD, RD, RN, PharmD, SW] Pathologist RD Registered Dietitian Nutrition Education NPO/ CLD Nothing by NST Nutrition Support mouth/Clear Liquid Diet Order Home Enteral or Parenteral Nutrition Supplies Team EMR/MR Electronic Order Oral Nutritional Supplements (Prescription, WIC form) MD Medical Doctor Medical Record or Medical Identify Medical Team for Home Management NP Nurse Practitioner Record Schedule Follow Up Appointment with Medical Team PA Physician Assistant HC Head circumference Place Home Care Orders (Home Weights, Nurse Visits) PharmD Pharmacist MUAC Mid-upper arm Obtain and Document Discharge Weight, Length, HC, MUAC circumference SW Social Worker Communicate