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Dietetic Assessment

The development and implementation of standard electronic documentation for the assessment of patients’ nutritional status within the Electronic Patient Record (EPR).

 

What’s changing?

  • Structured recording of electronic information within the EPR to record and monitor clinical activity within dietetics
  • New electronic assessment of patients’ nutritional status and risk
  • Automated referral to dietetics via EPR
  • All current dietetic documents within EPR will be expired

Specific changes

  • A new document has been created to assess the patient dietetic needs whether in an acute, home or clinic setting
  • The new document has clear plans documented for clinicians.
  • The current referral to the Dietitian is being updated to record more accurate reasons for referral
  • An automated referral to the dietitians can be generated from the Risk Assessment document, should the patient meet the required criteria
  • An automated order for Ensure Compact for seven days can generated from the Risk Assessment document should the patient meet the required criteria (A Patient Group Directive (PGD) has been developed to cover this)
  • A new document has been created to record regimes patients are on for Parenteral Nutrition. This document will auto generate an ‘Information Only Order’ with the associated ‘See Separate Cart’ task, which will inform clinicians that the patient is receiving this therapy.
  • A new document will be created for patients who have started Parenteral Nutrition Out of Hours. This document will auto generate an Information Only Order with the associated See Separate Cart task, which will inform clinicians that the patient is receiving this therapy. It will also create a referral to the PN team to advise them the patient has been started on the therapy out of hours
  • Two clinical summary tiles, one for the dietetic information and one for the parenteral nutrition information

 

Aim

  • Better nutritional care of all patients and better patient outcomes
  • Reduction in readmissions to hospital of elderly care patients 
  • Reduction in length of stay for patients in hospital
  • Prevent inappropriate referrals to the dietitians
  • Timely administration of dietetic supplements if a patient is scored as High on the MUST nutritional assessment
  • Reduction in duplication of documented information
  • Automated calculations within documents, saving dietitians time and providing accuracy
  • Shared and pre-populated fields within the assessment document, saving the dietitians time
  • Review of specified documented information at a glance, using the Clinical Summary tab

 

Purpose

  • Quicker and more effective referral to the dietetic team
  • Reduction of inappropriate referrals to the dietetic service
  • Increase in percentage of elderly care patients seen by dietetic service within 48 hours
  • Prevent patients started on Parenteral Nutrition out of hours being missed by the PN team and being delayed permanent therapy 

Background

 

All patients should undergo a Risk Assessment within four hours of being admitted to hospital. Within this assessment the patients’ nutritional status is scored, using the Malnutrition Universal Screening Tool (MUST).

Standardising of the dietetic documentation within the EPR and updating the information on the referral means more accurate information is inputted and will enable the team to see the correct patients in a quicker time frame. This should in turn reduce waiting times and free up staff time to undertake the necessary initial and follow up assessments.

 

For more information:

Please contact the project lead Chris Slater  - chris.slater@srft.nhs.uk

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