Aalborg University, Denmark.
The University of Adelaide, Australia.
Health Informatics J. 2020 Mar;26(1):248-263. doi: 10.1177/1460458218824707. Epub 2019 Jan 25.
Providing the best possible nutritional care requires accurate and precise communication between healthcare professionals. Developing a Nutrition Minimum Data Set will inform professionals in primary healthcare of which core elements should be documented and facilitate a standardized approach to the documentation of nutritional care. A two-step methodological approach was utilized in this study: (1) a systematic scoping review was conducted to map evidence underpinning the development of a Minimum Data Set and (2) the datasources were categorized using the inductive content analysis approach. A total of 32 items were identified in the datasources. Five categories were inductively derived from the data: (1) physiologic measurements, (2) ability to eat, (3) intake, (4) stress factors and (5) factors which indirectly affect intake and needs. Organizing the documentation following the structure presented in this Minimum Data Set will contribute to a standardized terminology, which may lead to increased quality of documentation, increased continuity of care and improved health outcomes.
提供最佳的营养护理需要医疗保健专业人员之间进行准确和精确的沟通。制定营养最低数据集合将告知初级保健专业人员应记录哪些核心要素,并促进营养护理记录的标准化方法。本研究采用了两步方法论方法:(1)进行系统的范围审查,以绘制支持最低数据集合开发的证据,(2)使用归纳内容分析方法对数据源进行分类。在数据源中总共确定了 32 个项目。从数据中归纳出五个类别:(1)生理测量,(2)进食能力,(3)摄入量,(4)应激因素和(5)间接影响摄入量和需求的因素。按照本最低数据集合中提出的结构组织文档将有助于标准化术语,这可能会提高文档的质量,提高护理的连续性并改善健康结果。