Toward a single source of truth: The case for centralized nutrition documentation in electronic medical records

Nutrition is an essential component of care for all patients. However, electronic medical record (EMR) systems lack a centralized location for nutrition-related information. The absence of standardized documentation and workflows is misaligned with key domains of healthcare quality as defined by the Institute of Medicine- namely, safety, patient-centeredness, and efficiency. This study aims to identify opportunities for EMRs to enhance nutrition evaluation, management, and safety.

A 12-item online survey was developed and distributed to pediatric healthcare providers to assess current practices in EMR documentation of nutrition information, identify nutrition-related adverse events, and elicit suggestions for improvements. Descriptive statistics and the Kruskal-Wallis test were utilized to analyze quantitative survey data. Qualitative data were analyzed thematically to identify key concerns and a core theory reflecting respondents' perspectives.

One-hundred and fifteen participants completed the survey, resulting in a response rate of 23%. Only 54% of participants reported having a standardized EMR workflow for documenting food allergies and intolerances. Multiple challenges were reported in locating nutrition plans within the EMR, including absence of a standard location for information, lack of order interoperability across settings, and inconsistent information. Most respondents (73%) reported awareness of nutrition-related safety events at their institution.

There is a critical need to optimize and standardize nutrition documentation within EMRs. Healthcare providers are calling for a unified, integrated system that distinguishes food allergies and intolerances, enhances the visibility of essential nutrition data, and links dietary information across departments and care settings to improve patient safety and care coordination.