Introducing a standardised documentation process into a community health organisation

摘要

Background: The Nutrition Care Process Terminology (eNCPT) is not routinely used in some dietetic practice areas such as community health and weight-neutral care. Standardised terminology is paramount in the community health care setting which comprises multiple APDs working across multiple sites. Many community dietetic services offer weight-neutral care, and are under organisational pressures to demonstrate service effectiveness. Utilising weight neutrally consistent eNCPT in this context will therefore provide a systematic approach to demonstrating the effectiveness of the dietetics care provided. Aim: To design and implement standardised documentation and reporting methods incorporating the eNCPT in community dietetic service providing weight-neutral care. Methods: A user-centred design process was used to embed the eNCPT in current documentation practices and to re-design forms used by the dietitians to document the nutrition care process. Acceptability of the new documentation forms and process was evaluated using one-on-one interviews. Data were qualitatively analysed. Results: The new documentation forms and process were well accepted by the dietitians, one week after the design process was completed and training was provided and agreed it aligned with weight neutral approach. Conclusions: The eNCPT is an essential part of the nutrition care process that all dietitians, regardless of practice area, can be implementing. This project demonstrates that it can be implemented in community dietetics services where systematic implementation of standardised terminology is relatively novel. The eNCPT will therefore support future efforts for further research measuring the effectiveness of services provided in the community.