LEARNING OUTCOME: To evaluate two formats for documentation of initial nutrition assessment in the acute-care patient medical record.

Documentation of initial nutrition assessment at one institution was completed in subjective, objective, assessment, plan (SOAP) format until 1994, when an Assessment Form was initiated to streamline the standardized documentation of R.D.s. The two formats were evaluated to determine the effectiveness of dietitians documentation practice. A retrospective chart review was completed using a random sample of charts from two groups of patients (SOAP/94, n=30; FORM/95-96, n=30) with a primary discharge diagnosis of cerebrovascular accident. Initial assessment documentation was completed sooner in the FORM/95-96 group (2.61 days) than the SOAP/94 group (4.31 days). Significantly more recommendations (p=<.001) for nutrition intervention were made in the FORM/95-96 (n=25) than the SOAP/94 group (n=9). For both groups significantly more recommendations were made by the R.D. when documentation was completed earlier in the patient hospital admission. The FORM/95-96 group showed an increasing trend in the total number of recommendations made by the R.D. and implemented by the Healthcare provider. Assessment form documentation, used with the FORM/95-96 group, for initial nutrition assessment was completed more frequently, in a more timely manner, and provided appropriate nutrition recommendations for patient centered care in the acute hospital setting.