Which data should we collect from nutritional counseling and therapy and how can we ensure these data are included in hospital discharge letters?
- 05.10.2022
- English Articles
- Mareike Krämer
- Maren Peuker
- Nadja Noll
- Laura Hoffmann
- Roland Radziwill
- Kathrin Kohlenberg-Müller
Peer reviewed / Manuscript (original) submitted: 16 July 2021 / Revision accepted: 13 November 2021
Development of a structured documentation concept to facilitate the integration of nutrition-related patient data into discharge management – a case study1
Background
On October 1, 2017, the Framework Agreement on Discharge Management, which is legally binding for hospitals under Section 39 (1a), Volume V of the German Social Security Code (Fünftes Buch Sozialgesetzbuch – SGB V), came into force. This agreement sets out requirements for “patient-specific, resource-oriented and participation-oriented” [1] discharge management during the transition to post-hospital care and aims to ensure that care is needs-based, continuous, and consistent across sectors. The agreement provides follow- up care providers, including those in dietetics, the opportunity to continue providing therapy in an effective and efficient way [1].
The discharge letter, which is key to discharge management, should contain all the information required for the patient’s further treatment and follow-up care. In particular, it should document all of the treatment data collected from the various professional groups involved in the treatment process. Nutritional therapy services carried out in the hospital should therefore also be included in the discharge letter. Section 9 of the Framework Agreement on Discharge Management, “Documentation to be provided to the physicians providing further treatment”, specifies the minimum information that is required, however the lists of requirements are to be understood as overarching, interprofessional requirements and they do not specify exactly which dietetic data should be documented [1]. ...
Abstract
Documenting dietetic data in a structured way so that it can be integrated into mandatory discharge management is a challenge for hospitals. This study developed a documentation concept for the data that is to be documented in nutritional counseling and therapy, taking process-guided working methods into account, and compared it with current practice in a case study. The target/actual comparison shows that current documentation is unstructured and incomplete due to a lack of structural resources and personnel, and due to a lack of an implementation strategy. The study identified necessary adjustments and recommendations for action. The documentation concept represents a decisive step forwards in terms of expanding the discharge letter to include dietetic data. Further studies on implementation in practice are needed.
Keywords: Nutritional therapy, Dietetic Care Process, documentation, discharge management, interprofessional interface management
