Quality statement 3: Documentation and communication of results and nutrition support goals

Quality statement 3: Documentation and communication of results and nutrition support goals

Quality statement

All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable), documented and communicated in writing within and between settings.

Rationale

Documentation and written communication of a person's nutrition screening results and any nutrition support goals is important for ensuring continuity of care both within settings and after transfer between settings. This also helps to manage significant patient safety issues, such as nutrition support not continuing when it is required or people being given inappropriate food for their circumstances.

Quality measure

Structure: a) Evidence of local arrangements to ensure that a person's screening results and nutrition support goals (if applicable) are documented and communicated in writing when a person transfers within and between settings.

Process: a) The proportion of people screened for the risk of malnutrition whose screening results and nutritional support goals (if applicable) are documented in their care plan.

Numerator – the number of people in the denominator whose screening results and nutritional support goals (if applicable) are documented in their care plan.

Denominator – the number of people in a care setting who meet the criteria for screening (see statement 1).

b) The proportion of people screened for the risk of malnutrition whose screening results and nutritional support goals (if applicable) are communicated in writing within and between settings.

Numerator – the number of people in the denominator whose screening results and nutritional support goals (if applicable) are communicated in writing.

Denominator – the number of people transferred within or between settings and who have been screened for the risk of malnutrition.

What the quality statement means for each audience

Service providers ensure systems are in place to document and communicate in writing the results of screening for the risk of malnutrition and, if applicable, nutrition support goals, when a person transfers within and between settings.

Health and social care professionals document and communicate in writing the results of screening for the risk of malnutrition and, if applicable, nutrition support goals when the person transfers within and between settings.

Commissioners should ensure they commission services with systems in place to document and communicate in writing the results of screening for the risk of malnutrition and, if applicable, nutrition support goals when a person transfers within and between settings.

People who are screened for the risk of malnutrition (not getting enough calories and nutrients such as protein and vitamins, to meet the body's needs) have the results of their screening and the goals of any nutrition support (such as special nutrient-rich foods, nutritional supplements and fortified foods, or liquid food given through a tube) they are having recorded and communicated in writing when they transfer within and between settings.

Source guidance

NICE clinical guideline 32, recommendations 1.9.1, 1.9.2, 1.9.5.

Data source

Structure: a) Local data collection.

Process: a) and b) Local data collection. Acute hospitals, care homes and mental health trusts can review historical data on screening rates by reviewing the previous findings of the annual national nutrition screening survey conducted by the British Association for Parenteral and Enteral Nutrition (BAPEN).

Outcome: Local data collection.

Definitions

Results

Identification of a person's malnutrition risk category that is recognised across care settings, including 'no risk' (this should also be communicated within and between settings).

Goals

The aims of any nutrition support that is documented in the management care plan, agreed following review of the person's risk of malnutrition.

Documented

The results from the screening should be documented in the person's care records and linked to a care plan. People who are identified as well-nourished will usually continue with routine care. For people identified as malnourished, the specific care plan and nutrition support goals should be clearly documented.

If applicable

For people screened who are not malnourished or at risk of malnutrition, the results should be recorded in their care plan but they do not need specific nutrition support goals.