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Development of a nutritional documentation tool: a Delphi study.

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Summary
This summary is machine-generated.

This study developed and tested a new nutritional documentation tool (NDoc) to improve patient care information transfer. The evidence-based NDoc tool enhances nutritional data integration in clinical practice.

Keywords:
ESPEN European Society for Clinical Nutrition and Metabolism.Discharge lettersDischarge reportsNutritional care processesNutritional documentationPatient dischargeStandardised terminology

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Area of Science:

  • Clinical Nutrition
  • Health Informatics
  • Patient Care Management

Background:

  • Effective information transfer between care settings is crucial for high-quality patient care.
  • Nutritional information is often inadequately integrated into current medical information transfer processes.
  • An evidence-based approach is needed to standardize nutritional documentation.

Purpose of the Study:

  • To develop a novel nutritional documentation tool (NDoc) grounded in scientific evidence.
  • To evaluate the usability of the NDoc tool in real-world clinical settings.
  • To facilitate the integration of essential nutritional data into patient care.

Main Methods:

  • Conducted a comprehensive literature review to identify core content for nutritional documentation.
  • Utilized a modified Delphi survey with European experts to refine and collect essential data points.
  • Developed a structured 30-item NDoc tool based on gathered evidence and expert consensus.
  • Assessed the usability of the NDoc tool through daily practice testing by primary care and clinical physicians.

Main Results:

  • A structured, evidence-based nutritional documentation tool (NDoc) with 30 items was successfully developed.
  • The NDoc tool demonstrated usability in daily clinical practice among physicians.
  • The tool is designed for integration into existing computer-based hospital information systems.
  • The NDoc is adaptable for regional and potential worldwide implementation.

Conclusions:

  • The developed NDoc tool provides an evidence-based solution for integrating nutritional information into patient care.
  • The NDoc tool is usable and can enhance the comprehensiveness of medical information transfer.
  • Implementation of the NDoc tool can support improved patient outcomes through better nutritional data management.
  • The NDoc tool offers a scalable and adaptable framework for standardized nutritional documentation globally.