Abstract：
BACKGROUND: The nutrition care process (NCP) is a four-step systematic approach to guide dietitians in providing high-quality nutrition care. It fosters critical thinking and enhances the consistency of dietitians\' documentation. Following international recommendations, University Training Hospital of Fribourg (HFR) implemented it in 2013. This study aimed to evaluate the quality of NCP documentation in electronic patient records (EPRs) and to determine the nutrition problems dietitians most often identified while documenting their actions.
METHODS: The audit was performed on 92 EPRs using the Diet-NCP-Audit, which was translated into French for this study.
RESULTS: The documentation quality was assessed as high in 62% of the EPRs, and nutrition diagnoses were mostly documented. In half of the EPRs, nutrition assessment (step 1 of the NCP) was inconsistent with nutrition diagnosis (step 2). Dietitians often used the same nutrition problems: out of the 73 nutrition problems defined in NCP terminology, only 4 (5%) represented 58% of the 189 problems identified in the EPR audit.
CONCLUSIONS: EPRs were mostly assessed as high quality. However, the entire process requires improved consistency. The poorly documented link between the NCP steps and the restricted choices of nutrition problems dietitians identified should be addressed because they could reveal that dietitians have not fully adopted critical thinking, which the NCP stresses.
METHODS: The audit was performed on 92 EPRs using the Diet-NCP-Audit, which was translated into French for this study.
RESULTS: The documentation quality was assessed as high in 62% of the EPRs, and nutrition diagnoses were mostly documented. In half of the EPRs, nutrition assessment (step 1 of the NCP) was inconsistent with nutrition diagnosis (step 2). Dietitians often used the same nutrition problems: out of the 73 nutrition problems defined in NCP terminology, only 4 (5%) represented 58% of the 189 problems identified in the EPR audit.
CONCLUSIONS: EPRs were mostly assessed as high quality. However, the entire process requires improved consistency. The poorly documented link between the NCP steps and the restricted choices of nutrition problems dietitians identified should be addressed because they could reveal that dietitians have not fully adopted critical thinking, which the NCP stresses.
摘要：
背景：营养护理过程（NCP）是指导营养师提供高质量营养护理的四步系统方法。它培养了批判性思维，增强了营养师文档的一致性。根据国际建议，弗里堡大学培训医院（HFR）于2013年实施。这项研究旨在评估电子病历（EPR）中NCP文档的质量，并确定营养师在记录其行为时最常发现的营养问题。
方法：使用Diet-NCP-Audit对92个EPR进行了审核，这项研究被翻译成法语。
结果：在62%的EPR中，文档质量被评估为很高，和营养诊断大多记录在案.在一半的EPR中，营养评估(NCP第1步)与营养诊断(第2步)不一致.营养师经常使用相同的营养问题：在NCP术语中定义的73个营养问题中，在EPR审计中发现的189个问题中，只有4个(5%)占58%。
结论：EPR大多被评价为高质量。然而,整个过程需要改进的一致性。NCP步骤与营养师确定的营养问题的有限选择之间的不良记录联系应该得到解决，因为它们可以揭示营养师没有完全采用批判性思维，NCP强调。
方法：使用Diet-NCP-Audit对92个EPR进行了审核，这项研究被翻译成法语。
结果：在62%的EPR中，文档质量被评估为很高，和营养诊断大多记录在案.在一半的EPR中，营养评估(NCP第1步)与营养诊断(第2步)不一致.营养师经常使用相同的营养问题：在NCP术语中定义的73个营养问题中，在EPR审计中发现的189个问题中，只有4个(5%)占58%。
结论：EPR大多被评价为高质量。然而,整个过程需要改进的一致性。NCP步骤与营养师确定的营养问题的有限选择之间的不良记录联系应该得到解决，因为它们可以揭示营养师没有完全采用批判性思维，NCP强调。
