#152 - NUTRITION CARE PROCESS: AUDIT ON QUALITY OF MEDICAL RECORDS DOCUMENTATION BY DIETITIANS IN GOVERNMENT HOSPITAL SELAYANG Ahmed Khaled Abdulla Mohamed Ali Aljaberi1, Jamilah Binti Abd Jamil1, Winnie Chee Siew Swee1, L.Mageswari A/P Lapchmanan2, Teong Lee Fang2, Shanthi Dhandapani1.

NUTRITION CARE PROCESS: AUDIT ON QUALITY OF MEDICAL RECORDS DOCUMENTATION BY DIETITIANS IN GOVERNMENT HOSPITAL SELAYANG

ABSTRACT

Ahmed Khaled Abdulla Mohamed Ali Aljaberi1, Jamilah Binti Abd Jamil1, Winnie Chee Siew Swee1, L.Mageswari A/P Lapchmanan2, Teong Lee Fang2, Shanthi Dhandapani1.

1Department of Nutrition and Dietetics, School of Health Sciences, International Medical University Bukit Jalil, Kuala Lumpur; 2Department of Dietetics and Food Service, Hospital Selayang, Selangor.

BACKGROUND: In 2003, the American Dietetic Association (ADA) developed the nutrition care process model (NCPM). NCP is designed to improve the consistency and quality of individualised care for patients and clients, and to improve the predictability of outcomes. NCP was introduced in Malaysia in 2004, currently, it is mandatory for all government dietitians to implement the NCP in nutrition care. The objective of this study was to determine the quality of NCP documentation in a hospital that has implemented NCP and nutrition care process and terminologies.

METHOD: This is a retrospective audit of a total of 100 case documentation notes with at least one follow-up, comprising of 50 inpatient and 50 outpatient case documentation notes. Audit was done using a comprehensive NCP audit form by Jones S and Pratt D. The audit focused on completion status of documentation, and the linkage between the four steps of NCP; nutrition assessment, nutrition diagnosis, intervention and monitoring and evaluation and follow-up.

RESULTS: Total audit score for inpatient and outpatient departments was 79.8 (Good). There was a significant difference in the quality of documentation between inpatient and outpatient (P > 0.05). While outpatient departments scored a quality score of 78.5 (Good), inpatient attained a quality score of 81.2 (Good). Follow-up was the lowest scoring NCP section (72.3), while nutritional assessment is the highest scoring NCP section (87.8).

CONCLUSION: There was a significant difference in documentation quality between inpatient and outpatient departments in Hospital Selayang.

Keywords: NCP, ADIME, Quality, Documentation, Audit

Word count: 247 Words