PD039 - QUALITY OF CLINICAL NUTRITION RECORDS: AUDIT OF THE ELECTRONIC MEDICAL RECORDS OF HOSPITALIZED PATIENTS.

PD039

QUALITY OF CLINICAL NUTRITION RECORDS: AUDIT OF THE ELECTRONIC MEDICAL RECORDS OF HOSPITALIZED PATIENTS.

J. Regina Moraes¹, M. Shima¹, V. A. Cruz Ramis Figueira¹, M. M. Dourado Gomes da Silva¹, B. Jardini de Freitas¹, A. B. Bertossi Dreher², M. Nogueira Amorim de Lima², B. Fernandes da Silva², S. M. Fraga Piovacari^1,*

¹Clinical Nutrition, Einstein Israeli Hospital, ²Albert Einstein Israeli Faculty, São Paulo, Brazil

Rationale: To assess the compliance of clinical nutrition documentation in the electronic health records of hospitalized patients and to identify the main critical points in the documented care process. 

Methods: A descriptive, observational process audit analyzed 703 clinical nutrition records from electronic health records of hospitalized patients (February 2025–March 2026). Nutritional screening and assessment, sarcopenia risk, anthropometric data, nutrition therapy, educational plan, calf circumference, and nutritional progress notes were evaluated, with results expressed as compliance percentages. 

Results: A high level of compliance was observed in the initial indicators of nutritional care, including nutritional screening within 48 hours of admission (93.3%), initial nutritional assessment (98.2%), documentation of the nutritional monitoring date (99.2%), educational plan (95.8%), nutritional requirements at admission (93.7%) and during monitoring (90.8%), as well as the recording of calculated weight, calculated height, and BMI at admission (94.1%) and during monitoring (90.0%). 

In contrast, weaknesses were identified in indicators of greater clinical complexity, such as measured weight within the first 96 hours (71.3%), completion of the enteral/parenteral nutrition therapy form in applicable cases (82.5%), and screening for sarcopenia risk using SARC-F (82.0%). 

The most critical finding was the low frequency of calf circumference documentation, recorded in only 19.2% of eligible cases at admission and 21.2% during monitoring. 

Conclusion: The audit showed good adherence to initial nutritional documentation in the electronic health record. However, gaps remain in key indicators, particularly calf circumference documentation and completeness of nutritional progress notes. These findings highlight the need for ongoing monitoring and strategies to support clinical decision-making and patient safety. 

Disclosure of Interest: None declared