As a student at the Oriental Medical College in Santa Monica, I am able to partake in patient treatments in our clinic. There are about 30,000 patient visits per year. Upon arrival at the clinic, one of my first interests, of course, was reviewing and analyzing the patient's medical record forms and documentation. I find the documentation to be impeccable - but then again, each visit is close to an hour - unheard of in most physician offices (except for an initial consultation with a specialist). One of the key clinical elements for the oriental medicine (OM) practitioner is the patient's diet.
The OM practitioner asks about the typical diet (i.e. typical daily foods), amount of food, whether the patient craves certain foods, and, specificallly whether the patient omits certain foods (i.e. a vegetarian or vegan diet), eats alot of refined sugar, processed foods and/or dairy. The reason for the questions is, of course, to determine whether there is a relationship between the patient's symptoms and their food intake. Not only does the OM practitioner ask the questions, she also documents, in detail the patient's responses during the first visit. And, then she documents any changes in diet on each subsequent visit form.
The OM practitioner also asks the patient about his or her physical activity level....how much and what type of exercise the patient engages in on a regular basis. The record is a unit record, so it it easy to refer back to documentation on diet and physical activity from previous visits. The herbs that are prescribed and/or the acupuncture treatment that is given to the patient is then consistent with his chief complaint, symptoms, dietary practices, and physical activity level. My observations in the OM clinic got me thinking about how and if physicians document diet and physical activity in patient records in their offices or the hospital.
It seems to me that unless the patient is a diabetic or possibly suffering from malnutrition (hence the malnutrition query), I have not seen alot of documentation about dietary habits in the patient records I have reviewed in hospitals or physician offices. Afer a little research, I found that there are about a dozen medical schools (out of 126) that require physicians to take clinical nutrition courses. And, rumor has it that clinical nutrition courses for medical school students will likely become a requirement in the future. Furthermore, most of the big CME providers, like Harvard CMEs online, now offer physicians courses on nutrition and dietary counseling. I took one Harvard CME online course on the topic of Weight Management and physician's counseling of patients on readiness for change. The course also involved a review of exercise and fitness guidelines that physicians should share with their patients.
Education appears to be the guiding light for the evolution of patient record content. Dietary habits and physical activity are key. They will likely also play into pay for performance guidelines....like smoking cessation - if the physician does not ask and does not document dietary habits and physical activity, quality measures fall causing payment to fall as well. Is your patient record - whether an EMR or manual - capable of collecting patient dietary habits and physical activity in a way that is reliable and meaningful? Are physicians asking these types of questions of patients in your organization? And, is the CDI function poised to train physicians the best ways to document this type of activity?
