Dietetics:NutritionCare/Clinical Documentation 2018
Relevance of topic to dietetics student learning
- Charts are a compiled record of all treatments patient has received
- Used to monitor progression of treatment, maintain good communication between healthcare professionals, and ultimately facilitate patient-centred care.
Charting Sections Relevant to RDs:
- Screening - nutrition screening
- Assessments - ABCD
- Prescriber’s Orders - diet orders
- Progress Notes - SOAP/ADIME
- 1.01a,c: Demonstrate knowledge of federal and provincial/territorial requirements relevant to dietetic practice
- 1.02c,g: Demonstrate knowledge of regulatory scope of practice, standards of practice and codes of ethics, and principles of confidentiality and privacy
- 2.01e: Demonstrate knowledge of medical and dietetics-related terminology
- 2.02f: Provide accurate and relevant information in written material
- 3.03d: Identify strategies to communicate nutrition care plan with client, interprofessional team and relevant others
Summary of key principles
Charts are Legal Documents
Charts are part of the Freedom of Information and Protection or Privacy Act (F.I.P.P.A.). They help to maintain a record that highest standard of care was given and are audited for care quality and improvement. Charts are confidential documents and can be requested by patients. There are different policies, depending on the health authority, in regards to how to modify mistakes, how long charts are kept, and more. During internship, patient charts will need to be co-signed with your preceptor. As interns are not registrants of the CDBC, there is not a standard title; however, "Dietetics Intern" is commonly used. Check with your health authority/preceptor on what their policy is.
Please keep in mind that "Student Dietitian" is not allowed as "Dietitian" is a legally protected term.
SOAP vs. ADIME
As different charting methods are used in different health authorities, it is valuable to familiarize yourself with SOAP since you have practiced using ADIME in FNH 470 and FNH 475.
- So what is SOAP? SOAP stands for “Subjective Objective Assessment Plan”
- Standard format used by different health authorities in BC, including 4 sections
- Each section of a SOAP note requires certain information
- Subjective: Information you can’t measure
- Objective: Information you can measure
- Assessment or Action: Nutrition/Diagnosis
- Plan: How are you going to address the patient’s problem(s)
Abbreviations are not recommended during charting to avoid miscommunication (e.g. d/c can be interpreted as “discontinue”, but some may interpret it as “discharge”). However, abbreviations are still used throughout patient charts as well as conversations between healthcare team members. Here is a list of commonly used medical abbreviations to better prepare yourself!
Digital media learning resource #1: Charting Infographic
Here is an infographic to refer to during internship. It includes some key principles to charting, as well as some of the most common tips given by past interns and RDs.
Download the infographic here: Charting Infographic
Digital media learning resource #2: Charting Video
Watch this video for more practice on how to chart using SOAP! You can use the blank chart notes document while watching the video and then view the completed chart notes to compare. There are abbreviations used in this video to help you practice reading abbreviations in patient charts.
To get the most out of this activity, try filling out the form yourself before looking at the answers!
Online resources for further learning
UBC Dietetics website - Here is an in-depth resource that was created by previous Dietetics Students (2017) on charting:
UBC Dietetics video on charting - Here is a link to a Wiki page (with a video on charting) that goes over the process of charting, as well as the different sections of a chart:
Shadi A. Balanji, Amy Chen, Emma Clark, May Hasegawa, Janet See
Last updated: April 5, 2018