Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals-nurses, physicians, advanced practice providers, pharmacists, and dietitians-identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization's Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.

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优化营养保健电子健康记录的共识建议

提供营养保健对于进入医疗保健系统的任何患者的健康和福祉至关重要，无论是在门诊、住院还是长期护理环境中。跨学科专业人士——护士、医生、高级实践提供者、药剂师和营养师——在这些医疗保健环境中的每一个中识别和治疗营养问题或临床状况。从筛查和评估到出院，以结构化格式记录营养护理，可以交流营养治疗计划。本文档的目标是向临床医生提供建议，帮助他们与组织的信息系统部门合作，创建用于在电子健康记录中记录营养护理的工具。