PHYSICIANS PREFER GOAL-ORIENTED NOTE FORMAT MORE THAN 3 TO ONE OVER OTHER OUTCOME-FOCUSED DOCUMENTATION

To assess preference for outcome-focused nutrition notes, two note for mats were selected from the literature and tested against a modified, goal-oriented format. Focus charting and intervention, evaluation, and revision (IER) formats were compared with a charting-by-exception sty le that was modified to include goals and reassessment of risk. Notes were handwritten in each format and contained the same information. Ph ysicians were asked to choose their preference and explain why that fo rmat was selected. Initially, focus charting was tested against the go al-oriented format. The more popular of the two was then tested agains t the IER format. Nineteen physicians were surveyed by a registered di etitian for each comparison. Physicians preferred the goal-oriented fo rmat over focus charting and IER formats 9:1 and 3:1, respectively. In the first survey, physicians preferred the goal-oriented format becau se the plan was clearly stated, thereby rendering the note easier to u nderstand. The goal-oriented format was preferred in the second survey because the note was considered to be concise and easy to read and co ntained expected outcomes. Physicians want short communication that in cludes easily identifiable goals and plans. We recommend that experien ced dietitians use the goal-oriented format developed for this study, and preferred by physicians, for follow-up nutrition notes.