Evaluation of an electronic record prototype incorporating the Nutrition Care Process and International Dietetics and Nutrition Terminology

摘要

Aim: This research aimed to evaluate an online electronic record prototype incorporating the Nutrition Care Process and International Dietetics and Nutrition Terminology. Methods: Concept design and programming were conducted to create a prototype from an existing online records program. Twelve dietitians from Perth and surrounds trialled the prototype. Online anonymous questionnaires assessed attitudes and confidence around using the Nutrition Care Process and standardised terminology, current practices and opinions on the prototype. A focus group further investigated topics in more detail. Results: Part implementation of the Nutrition Care Process (e.g. nutrition diagnosis only) was reported by 42% of dietitians; the remainder planned to implement in the future. Developing new record systems was identified as the most costly area of implementation, followed by dietitian training. After trialling the prototype, dietitians reported an increase of confidence of 1 7% in using the terminology if they had access to an electronic system. Focus group discussions indicated dietitians felt the prototype was easy to use, acted as a guide to documenting using the care process and terminology, and would be useful in national e-health records. They expressed interest in using an electronic system for research purposes including quality control, investigating intervention effectiveness and justifying the role of dietitians on a productivity basis. Conclusions: Results of this pilot study support the concept that an electronic system using standardised terminology is likely to be well accepted by dietitians, and suggests further development of the prototype into a fully functioning system with scope for national electronic health record interoperability.