Sammanfattning
Background: With few exceptions, all adult patients admitted to somatic departments must be screened for nutritional risk. Nutritional risk is associated with a reduced nutritional status resulting from increased nutritional needs, as well as from reduced nutritional intake or uptake, due to illness or treatment. Patients at nutritional risk should receive individual interventions to prevent or treat malnutrition, and these interventions should be documented in the patient’s medical record.
Objective: The objective of this study was to assess whether the nutritional care provided at Haukeland University Hospital complied with the recommendations in the national guidelines on prevention and treatment of malnutrition.
Method: We performed a retrospective survey of nutritional data from medical records.
Results: We reviewed 714 medical records from eight somatic departments. Screening of the patient’s nutritional risk was documented in 107 medical records (15%). Altogether 64 patients were assessed within 24 hours of admission, and 26 patients were identified to be at nutritional risk. A nutrition plan was recorded for 18 of the patients, and energy needs were calculated and energy intake was documented for two of these patients. Twenty-six discharge summaries included malnutrition diagnostic codes, but they did not correspond to the documentation of nutritional risk.
Conclusion: Documentation of nutritional care in the medical records at Haukeland University Hospital was inadequate and did not comply with national guidelines. A national initiative under the Norwegian Patient Safety Programme provides a unique opportunity to improve nutritional practice at the hospital.