Does Documentation in Nursing Records of Nutritional Screening on Admission to Hospital Reflect the Use of Evidence-Based Practice Guidelines for Malnutrition?

作者：Geurden Bart^*; Wouters Conny; Franck Erik; Weyler Joost; Ysebaert Dirk

来源：International Journal of Nursing Knowledge, 2014, 25(1): 43-48.

DOI：10.1111/2047-3095.12011

• Evidence-based practice
• malnutrition
• nursing record

PURPOSE: To describe the documentation of nutrition-related data and wards referral to dieticians in a Belgian university hospital.
METHOD: Retrospective analysis of 506 nursing records.
FINDINGS: Body weight and height are documented in 22%. "Feeding assistance" and "usual food intake pattern" are documented in 68% of all cases, and in 71% it is marked whether the patient is on a diet. Eight percent of the patients are referred to a dietician, but the indications for these referrals are not clear.
CONCLUSION: Given the poor documentation, most likely these patients are not adequately screened for malnutrition as recommended.
IMPLICATIONS FOR NURSING PRACTICE: Nurses' documentation of nutrition-related data should be improved to facilitate treatment of malnutrition with tailored multidisciplinary interventions.

• 出版日期2014-2