DOCUMENTATION OF

NUTRITIONAL CARE
PROCESS
Presented by:
LUMBRE, MA. LUZVYLLE A.
MOVILLA, ROJEIL MARK N.
ODQUIN, SHEENA ROSE B.
Components of Medical Record
 Components of Medical Record

1.Demographics
• Non-medical information
• Identifying numbers, addresses, contact
numbers
• Information about race and religious
preference, occupation
• Health insurance information
• Emergency contacts
 Components of Medical Record

2. Medical History
• Surgical History, Obstetric History
• Medication
• Family History, Social History
• Habits
• Immunization History
• Growth and Developmental History
 Components of Medical Record

3. Medical Encounters
• Summary of an episode of care
• Outpatient or inpatient admission
• Includes:
• Chief Complaint, History of Present Illness,
Physical Exam, and Assessment of Plan
 Components of Medical Record

4. Orders
• Written orders by medical providers,
physicians, and nurse practitioners
• Must be signed
• Can find diet orders, lab orders,
medications, enteral and parenteral orders
 Components of Medical Record

5. Progress Notes
• Daily Updates
• May be in SOAP, narrative, or other formats
• Generally entered by all members of the
health care team
• Kept in chronological order
 Components of Medical Record

6. Test Results
• Blood tests, radiology exams, pathology,
specialized testing
• Often accessed online, even where there is
paper medical record
 Components of Medical Record

7. Other Information
• Flow Sheets
• Informed Consent Forms
• Family History, Social History
• Radiologic Images, EKG tracings, outputs
from medical devices
Standard Language and
Medical Abbreviations
Standard Language and Medical
Abbreviations

• ADIME (assessment, diagnosis,

intervention, monitoring and evaluation)
• DAP (diagnosis, assessment, plan)
• DAR (data, action, response)
• PIE (problem, intervention, evaluation)
• PES (problem, etiology, symptoms)
• IER (intervention, evaluation, revision)
Standard Language and Medical
Abbreviations

• HOAP (history, observation, assessment, plan)

• SAP ( screen, assess, plan)
• SOAPIER (subjective, objective,
analysis/assessment plan, intervention,
evaluation, revisions)
• SOAP (subjective objective,
analysis/assessment plan)
Problem-Oriented
Medical Records
Problem-Oriented Medical
Records
• Systematic documentation of a patient’s
medical history and care
• Used for physical document and body
information
• Intensely personal documents
• Should be complete, clear and concise
• Grammar and Spelling should be correct
Problem-Oriented Medical
Records
• Abbreviations that have multiple meaning
should be avoided
• Should be done at the time the service or
procedure is performed
• All entries should be signed
 Organization and Nutrition
Documentation
(SOAP,PES,ADIME, IER Notes, PIE Notes, Charting
by
exception)
 Organization and Nutrition
Documentation

1.SOAP (subjective objective, assessment, plan)

S- Subjective
• Information provided by patient, family, or other
• Pertinent socioeconomic, cultural information
• Level of physical activity
• Significant nutritional history
• Work schedule
 Organization and Nutrition
Documentation

O- Objective
• Factual, reproducible observation
• Diagnosis
• Height, age, weight, weight gain/loss pattern
• Lab data, Clinical Data
• Diet Order
• Medications
• Estimation of nutritional needs
 Organization and Nutrition
Documentation

A- Assessment
• Nutrition Diagnosis
• Interpretation of patient’s status
• Evaluation of nutritional history
• Assessment of laboratory data and medications
• Assessment of diet order
• Assessment of patient’s comprehension and
motivation
 Organization and Nutrition
Documentation

P- Plan
• Diagnostic studies needed
• Further workup, data needed
• Medical nutrition therapy goals
• Education plans
• Recommendations for nutritional care
 Organization and Nutrition
Documentation
SOAP EXAMPLE:
• S: Patient works night shift, eats two meals a day, before and after his shift; fried foods,
burgers, ice cream, beers in restaurants. Does not add salt to foods. Activity: Plays in
restaurants.

• O: 34 y.o. male s/p MI with history of htn, DM2, hyperlipidemia.

• Ht: 5 ft. 10 in; wt: 250 lb; BMI 36, Obesity II

• A: Excessive sodium intake (NI-5.10.2) related to frequent use of vending foods as

evidenced by diet history. Pt could benefit from increased activity and gradual wt loss
as recovery allows

• P: Provided basic education (E-1) on 3-4 gram sodium diet and wt management
guidelines
• Patient will return to outpatient nutrition clinic for lifestyle intervention and counseling
(C-2.1).
 Organization and Nutrition
Documentation
SOAP
PROS CONS
Common use by nutrition care Tends to encourage lengthy chart notes
professionals and other disciplines
Taught in most dietetics education One study suggests physicians are less
programs likely to respond to this format than
others
Easy to learn and utilize Downplays evaluation
Emphasizes legitimacy of objective over
subjective data