طراحی و اجرای نمونه‌ی اولیه‌ی پرونده‌ی تغذیه‌ای بیمار

Abstract

Background: The information on nutritional status as a part of patients' medical information should be documented on patient records by dietitians. Despite the importance of this information in the process of decision making and medical care and even legal aspects, no proper attention has so far been paid to documenting such information on patient records. This study aimed to design a prototype patient nutrition record (PNR) and implement it in teaching hospitals to determine its validity, efficacy and acceptability. Methods: This applied study was conducted in 2010-2011 in two steps. First, 6 forms of PNR including nutritional history sheet (in 2 pages), food frequency questionnaire (FFQ), daily nutritional status evaluation report, diet order sheet, parental/tube feeding order sheet, were designed. The forms were then implemented for 121 patients in endocrinology and internal medicine, pediatric, and orthopedic wards of two academic hospitals in Iran (Golestan Hospital in Ahwaz and Namazi Hospital in Shiraz) for a period 4 months. The opinions of 118 medical staff members on the implementation were collected by a questionnaire. The validity of the questionnaire was verified by academic experts and its reliability was confirmed by Cronbach's alpha. The obtained data was analyzed by descriptive statistics, analysis of variance (ANOVA) and independent t-test. Results: Mean scores of questions about the content and importance of nutritional information of the PNR and the implementation of the PNR were 4.14 and 4.1, respectively. No statistically significant differences between responses to questions and the hospitals, the type of career (medical specialist, nutritionist, and nurse), and the wards could be confirmed. Conclusion: Medical care practitioners that participated in this study accepted the prototype PNR. They confirmed that the high importance of integrating a PNR in patient records. Keywords: Medical Records; Nutrition; Patients; Information Management.