ABSTRACT
Introduction
High-quality clinical documentation is critical for ensuring patient safety, enhancing quality of care and outcomes management. Despite the recognised importance of standardised clinical documentation, particularly through the Nutrition Care Process (NCP) and its associated terminology, studies indicate flaws in current practices that may have negative impacts on patient outcomes and interprofessional communication. Regular auditing of clinical documentation could help in improving clinical documentation quality. Despite the availability of validation studies of clinical documentation audit tools, information on their use and dietitians’ requirements is lacking. This study aimed to investigate the dietitians’ use of clinical documentation audit tools internationally and to learn about their requirements for these tools.
Methods
A quantitative cross-sectional online survey was conducted in October 2021 using a newly developed and pretested 26-item questionnaire among dietitians identified through convenience sampling. The survey, developed through a multi-step approach including expert review and pretesting, collected data on clinical documentation audit tool use, purpose of auditing, preferred tool formats, and perceived enablers and barriers. Descriptive statistics and inferential analyses were applied to compare current practices and desired future applications of current auditors and non-auditors.
Results
A total of 154 respondents from 16 countries completed the survey, with more than half working in patient-related fields. Fifty-three percent indicated that clinical documentation audits were conducted in their workplaces Audit purpose was primarily improving clinical documentation quality, reinforcing NCP understanding, and enhancing clarity, with significant differences observed between current and desired uses regarding result comparability and quality reporting (p < 0.001). Key enablers included management support, education/training, time, and helpful manuals, while barriers included lack of knowledge, time constraints, and insufficient training. Auditors used the tools mainly in paper format (33%) or as a text processing/spreadsheet file (26%), with 51% preferring a web application in the future. Additional requirements included further manual development, benchmarking capabilities, and cross-cultural adaptations.
Conclusion
The process of clinical documentation auditing is not well established in the nutrition and dietetics community but has the potential to enhance clinical documentation quality. Key requirements include best practices for clinical documentation auditing processes, educational resources and user-friendly, web-based tools. Future research should validate clinical documentation audit tools across different settings and explore barriers to clinical documentation auditing as well as evaluating the use of artificial intelligence for clinical documentation auditing, ensuring improved clinical documentation quality translates to better patient care.
Journal of Human Nutrition and Dietetics, Volume 38, Issue 2, April 2025. Read More