Does documentation in nursing records of nutritional screening on admission to hospital reflect the use of evidence-based practice guidelines for malnutrition?

Purpose: To describe the documentation of nutrition-related data and wards referral to dieticians in a Belgian university hospital.

Method: Retrospective analysis of 506 nursing records.

Findings: Body weight and height are documented in 22%. "Feeding assistance" and "usual food intake pattern" are documented in 68% of all cases, and in 71% it is marked whether the patient is on a diet. Eight percent of the patients are referred to a dietician, but the indications for these referrals are not clear.

Conclusion: Given the poor documentation, most likely these patients are not adequately screened for malnutrition as recommended.

Implications For Nursing Practice: Nurses' documentation of nutrition-related data should be improved to facilitate treatment of malnutrition with tailored multidisciplinary interventions.