If you have been part or will be part of a Medical Records Review team at a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, you will be surprised how so many of the team members do not know the reason for nutritional screening which is the start of the the Nutrition Care Process – even among nurses in the team, and most will even not know where to find such evidence of nutritional screening in the medical record. Most of times, poor documentation in relation to the quality of nutrition documentation can be observed when nutritional screening data is not even gathered and forms left not filled appropriately.
In my opinion, it is the duty of the Medical Records Review team leader to highlight in his or her report non-compliance to nutritional screening among other findings, so that the hospital’s leaders can initiate a structured investigation to identify barriers to compliance for nutritional screening. I also strongly support that there must be an agreed standard for the type and context of screening tool(s) to be used, for example among a group of hospitals under an organisation. I believe standardisation facilitates research into barriers leading to poor documentation in relation to the quality of nutrition documentation, and this will lend credibility and usability of available screening tools for greater compliance.
Below is a diagram which summarises the steps in documenting hospital screening to identity patients with nutritional or functional needs, based on the previous post Hospital screening criteria data to identify patients with nutritional or functional needs (this link will open in a new tab of your current browser).
