ABSTRACT

High-quality documentation in patient records is essential for patient’s safety and plays a prominent role in the delivery and evaluation of dietetic/nutrition care. This study assessed the Nutrition Care Process documentation in patient’s record/folder in Federal Medical Centre, Asaba Delta State Nigeria. The study was a retrospective cohort study and a multi-stage sampling technique was used to select a total of 181 patient’s record. Data on background information, different category of NCP documentation (nutrition assessment, nutrition diagnosis, nutrition intervention, nutrition monitoring and evaluation) were collected using structured and validated questionnaire. The IBM SPSS version 22.0 computer programme was used to analyze the data. Data obtained were described using frequency and percentage. Pearson correlation was used to analyze the impact of compliance to NCP protocols on recovery and discharge and the association between the various NCP documentation.  Significant relationship was judged at p ≤ 0.05. Result revealed that documentation of nutrition assessment received the highest compliance where majority of the assessments identified food and nutrition history (99.4%), background and medical history (99.4%), biochemical, anthropometric data, nutrition focused physical finding (99.4%) and the appropriate standard were used (98.9%). A good number of them (48.1%) had a medium compliance, 46.4% had a high compliance while 4.4% had a low compliance to the Nutrition Care process documentation. Nutrition diagnosis and overall NCP score had an impact on the patient’s duration of hospital stay as there was a significant strong negative relationship between nutrition diagnosis and duration of hospital stay. There was a significant relationship between nutrition assessment, nutrition diagnosis and nutrition intervention. A significant relationship was also found between the overall NCP score and all the components of NCP and the overall NCP score (p<0.05). There is also a need to promote NCP/NCPT for all areas of nutrition practice, and develop strategic plans for implementation of the NCP and nutrition care process terminology. Providing nutrition practitioners with on-going education and clinical experiences in use and documentation of the nutrition care process and a standardized language may be indicated to increase the number of completed nutrition care process chains and improve documentation of nutrition care and patient outcomes.