Speaking the same language: Development of a Nutrition Minimum Data Set for healthcare professionals in primary healthcare

• Published in: Health informatics journal 2020-03, Vol.26 (1), p.248-263
• Main Authors: Håkonsen, Sasja Jul, Pedersen, Preben Ulrich, Bygholm, Ann, Peters, Micah DJ, Bjerrum, Merete
• Format: Article
• Language: English
• Subjects: Datasets; Documentation; Nutrition; Primary care; Standardization
• ISSN: 1460-4582; 1741-2811
• DOI: 10.1177/1460458218824707

Providing the best possible nutritional care requires accurate and precise communication between healthcare professionals. Developing a Nutrition Minimum Data Set will inform professionals in primary healthcare of which core elements should be documented and facilitate a standardized approach to the documentation of nutritional care. A two-step methodological approach was utilized in this study: (1) a systematic scoping review was conducted to map evidence underpinning the development of a Minimum Data Set and (2) the datasources were categorized using the inductive content analysis approach. A total of 32 items were identified in the datasources. Five categories were inductively derived from the data: (1) physiologic measurements, (2) ability to eat, (3) intake, (4) stress factors and (5) factors which indirectly affect intake and needs. Organizing the documentation following the structure presented in this Minimum Data Set will contribute to a standardized terminology, which may lead to increased quality of documentation, increased continuity of care and improved health outcomes.