Report on the first year of applying initial assessment of nutritional status in hospital inpatients

Abstract

Introduction. Since 2012, Polish hospitals are recommended to implement the assessment of the nutritional status and appoint nutrition support teams.

Aim. To evaluate the application of initial assessment of inpatients’ nutritional status in the first year of its implementation in clinical practice.

Material and methods. A retrospective analysis of medical documentation of patients admitted to hospital in the year 2012 was conducted. The research sample included one in ten medical records.

Results. A total of 433 medical records was analyzed. In 5.3% medical records a lack of duly completed Subjective Global Assessment questionnaires was revealed. In 81.8% cases a calculated Body Mass Index (BMI) was not found. No instances of renewed calculation of BMI were recorded. In 49.7% cases no information on diet recommended to the inpatient was found. With the exception of the internal medicine ward, in 87% of the cases the diets were not recommended in writing by a physician or included in the medical orders documentation. The inpatients classified as undernourished were usually recommended a diet containing 2000 kcal + additional 300 kcal as second breakfast and afternoon snack. Information on cooperation with the nutrition support team and on inpatient’s nutrition was not included in the nursing documentation.

Conclusions. During the first year when the obligatory patient nutritional status assessment was introduced in Polish hospitals, the awareness of its significance, nutritional therapy planning and monitoring of the results were insufficient. The assessment of nutritional status seems to be another dead letter in patient medical documentation.