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优化电子健康记录进行营养护理的共识建议。

Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care.

机构信息

American Society for Parenteral and Enteral Nutrition.

Academy of Nutrition and Dietetics.

出版信息

Nutr Clin Pract. 2020 Feb;35(1):12-23. doi: 10.1002/ncp.10433. Epub 2019 Nov 1.

Abstract

Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals-nurses, physicians, advanced practice providers, pharmacists, and dietitians-identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization's Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.

摘要

为任何进入医疗保健系统的患者提供营养护理至关重要,无论他们是在门诊、住院还是长期护理环境中。跨学科专业人员(护士、医生、高级执业医师、药剂师和营养师)在这些医疗保健环境中识别和治疗营养问题或临床病症。从筛查和评估到出院,以结构化格式记录营养护理可以沟通营养治疗计划。本文档的目的是为临床医生提供建议,与组织的信息系统部门合作,为电子健康记录中的营养护理文档创建工具。这些建议也可以为选择和实施医疗保健软件的医疗保健组织提供指导。

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