Nurses feel that they must protect patient autonomy by accepting the patient’s reluctance to eat (27), and expressed concern that standardisation of nutritional treatment does not meet individual needs and wishes. More knowledge about nutrition is essential for addressing such challenges. It is also important to have ongoing training related to screening, prevention and treatment of nutritional risk in order to advance knowledge and skills (18). It is the responsibility of management to ensure sufficient expertise on nutrition within the organisation.
Inadequate documentation of nutritional practice may also be due to the current documentation system, which is not well suited for documenting nutritional status and the patient’s food intake in a systematic, effective and user-friendly manner.
Our findings are confirmed by O’Connell, who concludes that standardised documentation on separate assessment forms in the medical record (27), as is the case at HUS, makes information less accessible than an updated electronic graph in the record. Therefore, we believe that developing appropriate documentation systems that can structure, simplify and improve documentation of nutrition is a pre-condition of adequate nutritional practice and important for integrating nutrition into clinical practice.
National initiative on nutrition
Our findings show that nutrition has a legitimate place in the Norwegian Patient Safety Programme: In Safe Hands. Such a large-scale, national initiative with implementation of the national guidelines for prevention and treatment of malnutrition is crucial for patient treatment and hospital budgets.
Intervention packages have been prepared, tested and found to be feasible for use in clinical practice, and they are ready to be introduced nationwide in 2018. Local barriers should be identified to ensure successful implementation of the intervention packages (29).
Strengths and weaknesses of the study
A strength of the study is that data were collected from a large number of medical records from a university hospital where the management has been concerned about nutrition for many years.
A weakness of the study is that we cannot rule out that different documentation practices were used, e.g. that information about weight, nutritional status and nutritional intervention may have been documented in places other than in the dedicated assessment forms in the medical records that we surveyed. To our knowledge, our study is the first of its kind in Norway that documents nutritional care by using medical record data.
A survey of medical record data showed that documentation of the nutritional care provided at Haukeland University Hospital was inadequate and not in compliance with the guidelines. The large-scale initiative on nutrition under the Norwegian Patient Safety Programme is a unique opportunity to incorporate adequate, systematic nutritional practice. Sufficient knowledge, skills, clear distribution of responsibility, routines and systems are a precondition for success.
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