Does Documentation in Nursing Records of Nutritional Screening on Admission to Hospital reflect the Use of Evidence-Based Practice Guidelines for Malnutrition?

This retrospective study analyzed 506 nursing records of adult patients admitted to a Belgian university hospital, aiming to assess the extent to which essential nutrition-related data are documented according to evidence-based guidelines for malnutrition screening. Only 22% of the records included both weight and height, and BMI was almost never calculated (0.3%). Other parameters, such as need for feeding assistance and usual food intake, were documented in 68% and 70% of cases respectively. Only 8% of patients were referred to a dietitian, with no clear criteria for referral. Documentation quality differed between surgical and non-surgical wards, with better results observed in non-surgical units. A longer hospital stay was negatively correlated with the completeness of documentation. The study concludes that documentation practices are insufficient, increasing the likelihood that malnourished patients are not identified or treated. The authors advocate for improved and systematic documentation by nurses to enable timely and individualized multidisciplinary nutritional interventions. The study also emphasizes the need for structured guidelines and automated systems to support nursing practice and effectively address hospital malnutrition.

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