Charles E J
Marriott Management Services, Atlantic City Medical Center, NJ 08401, USA.
J Am Diet Assoc. 1997 Oct;97(10 Suppl 2):S131-8. doi: 10.1016/s0002-8223(97)00748-7.
With charting by exception, only significant findings or exceptions to the norms are documented in script by the nursing staff. Upon admission, patients are screened for nutrition risk or need for nutrition education by nursing staff using an interdisciplinary patient database. Patients with predetermined criteria indicating nutritional risk or with nutrition education needs are referred to nutrition services. Using specified criteria, the clinical nutrition staff assign referred patients to a level of care. Nutrition care or education is provided and documented within 48 hours. Documentation varies with the level of nutrition care.
采用例外情况记录法时，护理人员仅在病历中记录重要发现或与规范不符的例外情况。入院时，护理人员使用跨学科患者数据库对患者进行营养风险筛查或营养教育需求评估。符合预定营养风险标准或有营养教育需求的患者会被转介至营养科。临床营养科工作人员根据特定标准为转介患者确定护理级别。营养护理或教育在48小时内提供并记录。记录内容因营养护理级别而异。
