Abstract
The present study surveyed the status of nutritional management records using the problem-oriented system (POS) for nutrition management of patients on dialysis, and examined several aspects during trial use of a nutritional management record model that we had developed. It is meaningful to develop an ideal nutritional management chart that allows efficient entry of a huge volume of nutritional data of the patients and is applicable to present and future clinical practice.
The survey was conducted in 2002 inviting registered dietitians in selected facilities to trial use of the new nutritional management record model. The model adopts a checking format compatible with critical path (CP) and electronic medical record. The results were analyzed and the usability and points for improvement of this model were examined.
Twenty-six facilities responded and a total of 140 cases were recorded and analyzed. POS-based items were entered in 90% or more cases in both the dialysis and nondialysis groups. Dietary items were entered in 60-90% of the cases in both groups. These results together with suggestions from dietitians after trial use identified various aspects that need improvement, such as the format, recording items and ease of use. These data are useful for further development of an ideal nutritional management chart.
In the future, nutritional management charts using a simple recording method and a common language applicable to evidence-based medicine (EBM) and easily understandable by other health care staff will allow effective use of the information in clinical practice. Such charts will also be applicable to team care, critical path, and electronic medical record.
