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Advances in Health Sciences Research, volume 31
Proceedings of the 1st International Scientific Meeting on Public Health and Sports (ISMOPHS 2019)
Electronic Nutrition Care Process Accelerate the
Documentation Time at Saiful Anwar Hospital Malang
1,* 2, 3, 4
Farah Paramita Yayuk Hartriyanti Susetyowati Lutfan Lazuardi
1 Department of Public Health, Faculty of Sport Science, Universitas Negeri Malang, Malang, Indonesia
2 Department of Health Nutrition, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
3 Department of Health Nutrition, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
4 Department of Health Policy and Management, Faculty of Medicine,Universitas Gadjah Mada, Yogyakarta,
Indonesia
* Corresponding author Email: farah.paramita.fik@um.ac.id
ABSTRACT
Nutrition care is one of hospital health care that needs an information system to support documentation of Nutrition
Care Process. There are some barriers in implementing NCP, one of them is lack of time in implementing Nutrition
Care Process. Computer based information system is expected to be a solution to overcome the barrier. Some studies
show that using computerized information system is faster than manual system. Nutrition Care Process (NCP)
Electronic is a computer based application that processes data and records nutrition care information. This application
was tested by compare it with manual documentation system to find out which documentation system was faster. The
main objective of this study was to compare manual and computer based documentation system using NCP Electronic
in Saiful Anwar Hospital. This was pre experimental study with one group pre-post test design. Eight Dietitians in
Internal Medicine Department were involved to documenting 40 Diabetes Mellitus type II patients. Dietitians
documented nutrition care process patients with both manual and electronic system. Data were collected by observing
documentation time process. Statistical test was perform using paired t-test. Documentation using NCP Electronic was
faster than manual system. It took 6.34 minutes using NCP Electronic which was faster 2.20 minutes than manual
system. Significant difference were note between documentation time using NCP Electronic and manual system (p<
0.05). There were significant different between documentation time using NCP Electronic and manual system. NCP
Electronic documentation time was faster 2.20 minutes than manual system.
Keywords: Dietetics, Documentation, Medical informatics application, Time and motion, Nutrition care
process.
1. INTRODUCTION Implementation of NCP in fact face some barriers.
One of the major barrier to implement NCP is much
Information system is very important to support time needed [3]. Study about NCP Implementation in
Nutrition Care Process (NCP). Nutrition Care Process is Hasan Sadikin Hospital showed that documentation of
a systematic problem-solving method that nutrition nutrition assessment and diagnosis was uncompleted
professionals use to think critically and make decisions because dietitian wanted to save time [4]. Another study
that address practice-related problem [1]. NCP consist showed that manually calculating nutrition requirement
of 4 systematic steps, there are Nutrition Assessment, in patient was not demonstrated because of lack of time
Nutrition Diagnosis, Nutrition [5]. Computer based information system is expected to
Intervention, Nutrition Monitoring and Evaluation. be a solution to overcome the barrier.
Nutrition Care Process include collecting data, Information system both manual and computer have
processing data and documenting data to produce to provide good quality of information. Some studies
important information for dietitian. Using information showed information quality using computer information
system for dietitian has a great benefit to manage much system in time dimension. It showed that using
information for making decision [2]. computer system is faster than manual system. Using
Copyright © 2020 The Authors. Published by Atlantis Press B.V.
This is an open access article distributed under the CC BY-NC 4.0 license -http://creativecommons.org/licenses/by-nc/4.0/. 123
Advances in Health Sciences Research, volume 31
computer system reduced 68% time to calculate nutrition diagnosis, nutrition intervention and nutrition
nutritional needs and menu planning in patients monitoring and evaluation’s plan
compared to manual system [5]. The other studies also
showed that using computer system to document NCP 3. RESULTS
was 13 minutes faster than paper-based system [6]. 3.1. Nutrition Care Process Documentation In
This study used computer based system to help Saiful Anwar Hospital
dietitians record NCP. It can process data and record
nutrition information. This computer system record all Saiful Anwar Hospital has implemented Nutrition
NCP steps, automatic calculator and provide electronic Care Process since 2006. Saiful Anwar hospital become
International Dietetic and Nutrition Terminology role model for other hospital also university as good
(IDNT) as a standardized language of nutrition to place to study NCP implementation.
perform nutrition diagnosis. Used of NCP Electronic is Nutrition care documentation already include in
expected to help dietitian completing their task easily, medical record since 2014, integrated with the other
faster and accurate. This computer system is still in health care documentation. There are 8 nutrition
development stage that need to be tested by documented documentation form should be recorded by dietitian,
NCP patient in hospital setting. This study was Nutrition Screening Form, Nutrition Assessment Form,
performed by dietitian in Internal Medicine Department Problem Identification Form, Nutrition Planning Form ,
Saiful Anwar Hospital. We performed this study at Integrated Patients Progress Form, Nutrition Progress
Saiful Anwar Hospital because NCP have been Form, Nutrition Resume Form and Nutrition Education
implemented as their daily basis nutritional care. We Form.
compare NCP documentation in typed II Diabetic
Mellitus inpatients patient. The objective of this study NCP begin with nutritional screening to find
was to compare time different between NCP malnutrition risk in patient. Parameter used in screening
documentation electronic with manual paper-based test was weight change in last 6 months, decreased food
documentation. appetite and special condition existed in patients like
diabetes mellitus, chemotherapy, hemodialysis ect.
2. METHOD Nutrition assessment in patients was collecting data
This was pre-experimental study with one group pre- process like anthropometry, biochemical, physical and
post test design. Study was held on Saiful Anwar clinical condition, dietary, and patient history.
Hospital Malang. This was Pre-experimental study Documentation of nutrition assessment is recorded in
because NCP Electronic was used only on trial phase. Nutrition Assessment Form. After all nutrition
There were two phase in this study, first was manual assessment data has been collected, dietitian should
documentation system phase that completed as usual identify nutrition problem occurred in patients. The next
with paper based in service hours. Documentation of step of NCP is nutrition diagnosis, nutrition intervention
NCP used medical record. The next phase was and nutrition monitoring and evaluation plan. This
electronic documentation system that completed using process recorded in Nutrition Planning Form. This form
NCP Electronic application after service hours. Data consist of review problem identification, nutrition
input in electronic system phase was based on Data diagnosis, nutrition intervention and nutrition
Collection Form given from investigator of the study. monitoring and evaluation plan.
Population of this study was NCP Documentation in Nutrition diagnosis written with PES format
typed II Diabetic Mellitus (DM) inpatient patients in (Problem Etiology Sign Symptom) using standard
Internal Medicine Department of Saiful Anwar Hospital. language from International Dietetic and Nutrition
New diabetic mellitus patients who has malnutrition risk Terminology 3 which already translated into Bahasa.
(scored ≥ 2) in screening result chosen to be sample of Nutrition intervention consist of type of diet with
this study. The sample size of this study was 40 DM nutrition needs like energy, carbohydrate, protein and
typed II patients documentation both in manual and fat from hospital standard diet. Dietitian also record
electronic system. Eight Dietitians from Internal nutrition education for patients by written education
Medicine Department was join this study. The inclusion material. Nutrition Monitoring and Evaluation Form
criteria of dietitians who perform the documentation consist of documentation of indicator used by dietitian
were already received NCP training and have ability to to monitor and evaluate patient based on assessment
operate computer. data record. This study limit the observation only in
assessment, diagnosis, intervention and monitoring and
Data collection included time spent to record NCP evaluation plan. Documentation observation of this
documentation both with manual and electronic system. study limited only in Nutritional Assessment Form,
bservation of process and document of Nutrition Care Problem Identification Form andNutritional Plan form.
Process documentation including nutrition assessment,
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Advances in Health Sciences Research, volume 31
3.2. Dietitian Characteristic 3.3. Comparation Between NCP Manual and
This study involved by 8 Dietitians who meet our NCP Electronic
inclusion criteria form Internal Medical Department. Before data collection process begin, we make
The characteristic of dietitian is list down in the Table 1. adjustment for NCP Electronic so every part of NCP
Table 1. Dietitian characteristic manual in medical record include in NCP Electronic.
Table 2 list the difference part in NCP manual and NCP
Characteristic n Electronic.
Age (year)
< 30 year 7 Table 2. Comparation between ncp manual and ncp
> 30 year 1 electronic
Gender Nutrition
Man 2 No Care NCP Manual NCP electronic
Woman 6 Component
Working experience Patent ID
< 1 year 1 Patient Name
> 1 year 7 Date of Birth
NCP training Address
Gender
No 0 Age
Yes 8 Personal Medical Record Religion
Education 1. Data ID Patient Name Education
DIII 3 Date of Birth Job
DIV/S1 5 Dianosis
Computer ability Dietitian
Poor 0 Room
Good 8 Record Date
Record Time
Dietitians who involved in this study mostly aged Weight
less than 30 with working experience at least 9 months. Weight (complated with
Before this study was conducted, dietitians have estimation
received NCP training from Saiful Anwar Hospital also formula)
tutorial how to operate NCP Electronic from Height
investigator. All the dietitians who participated in this Height (complated with
study also have ability to operate the computer at least estimation
Ms. Office and Windows. formula)
Ideal Body Ideal Body
Eight dietitians recorded 40 nutrition care Weight (IBW) Weight
documentation DM typed II patients both manually and Body Mass MUAC
electronically with NCP Electronic. These Dietitians Anthropo- Index (BMI)
spread in several rooms including Room 22, 24B, 24C, metry Nutritional
25, 26, 27, 28, 29, Pulmonary, Cardiovascular Care Unit Knee High Status (% MUAC
(CVCU), Stroke Unit (SU), and Pulmonary High Care 2. dan BMI)
Unit (PHCU). One Dietitian work in one room, but there Nutrition
are 3 dietitians who worked in 2 rooms, CVCU and SU, Heigh Problem
Room 26 and PHCU, Room 24 and 29. Estimation Identifiication
Fourty DM typed II cases was divided equally by MUAC Waist
eight dietitians, so each dietitian should record 5 DM Circumference
cases both manually and electronically. During data % MUAC Hip
collection process, DM typed II patients were difficult Circumference
to find in some room. Because of that, investigator Nutritional Waist Hip Ratio
added another case beside DM typed II (cancer, kidney Status
disease, heart disease and cardio vascular accident Biochemi- Laboratory Data
(CVA)) to obtain relatively the same number of cal Laboratory Data Problem
documentation. Investigator done this in order to get Identification
relatively the same documentation load for dietitians. Physical Physical and Physical and
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Advances in Health Sciences Research, volume 31
Nutrition From the table above known that every part should
No Care NCP Manual NCP electronic be input in NCP electronic is the same with NCP
Component manual. The different things is only on categorize, like
and Clinical Clinical Data Clinical data past medical history and current medical history were
Past Medical on the medical history part but in NCP Electronic is on
history physical and clinical part. Problem identification part in
Current Medical NCP manual available on Problem Identification Form
History but in NCP Electronic, is input manually in every part of
Problem nutrition assessment from anthropometry to dietary and
Identification automatically will be shown in nutrition diagnosis part.
Family medical It will be easier for dietitians to make nutrition diagnosis
history based on problem identification result.
Allergy Allergy The different things between these two type of
Dietary Dietary intake Dietary intake documentation is the NCP electronic has automatically
History pattern pattern formulation for nutritional status, and ideal body weight
(Past) Menu Menu calculation. It also has automatically formulation for
Breastmilk Breastmilk weight and height estimation.
feeding feeding Documentation with NCP electronic contain more
Food Appetite Food Appetite data than NCP manual, even though only data shown in
Swallow Swallow NCP manual should be recorded by in NCP electronic.
Dietary diffculty, chewin diffculty, chewin It was helped by Data Collection Form to make data in
History difficulty, difficulty, NCP manual is the same with NCP electronic.
(Current) nausea, vomit nausea, vomit
Parental/enter- Parental/enteral 3.4. Documentation Time Between NCP
al Problem Manual and NCP Electronic
identification
Problem The documentation time of NCP Electronic was
Problem identification Found in every faster than NCP manual. Dietitians took 6.34 minutes in
3. identificati- found in every part of average when using NCP Electronic and took 8.14
on part list down assessment minutes in average when they use NCP manual. Total
here documentation time average using NCP Electronic was
Nutrition Nutrition faster 2 minutes 20 seconds than NCP manual. Pair t-
4. Nutrition diagnosis diagnosis test showed that the documentation time has
Diagnosis written in PES written in PES significantly different between NCP manual and NCP
format format Electronic (p<0.05). It can be seen at Table III.
Hospital Hospital
Standart Diet Standart Diet Table 3. Documentation time between ncp manual
Nutrition Nutrition and ncp electronic
Compositing in Compositing in NCP
Nutrition Standart Diet Standart Diet Variable NCP Manual p
5. Interventi- Nutrition Nutrition Electronic
on Education Education Documentation 8.141.94 8.141.94 0.0003
Type of food Time (minutes)
Route of
administration 4. DISCUSSION
Other
information Statistical result showed that documentation time
Monitoring Monitoring and Monitoring and using NCP electronic was faster than NCP manual. The
6. and Evaluation Evaluation same result was found in previous study that electronic
Evaluation Indicator Indicator system could accelerate nutrition care process in
Record date In personal data hemodialysis patients. That study showed that nutrition
part assessment process using electronic system is faster than
7. etc Signiture and Replace with paper based system [6]. The other study stated the same
dietitian name name of result that using electronic system could reduce
Dietitian dietitians time 68% than manual system [5]. Survey that
has been performed in University of Illinois Hospital
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