Documentation of Patient Weights by Clinical Care Staff in a Rural, Regional Medical Center

Abstract

Weight loss over a specific time period is an important indicator for recognizing malnutrition in hospitalized patients. Documenting accurate weights in the electronic medical record is crucial to identify and treat malnutrition. The purpose of this project was to evaluate clinical care staff compliance with documenting patient weight. A medical record review was performed on 7 randomly selected days (n = 122) over a 5-week period. Documented weight and method of obtaining weight were recorded. Weight information was documented 91.2% of the time. Objective methods of obtaining patient weight were used 77.9% of the time, while subjective methods were used 13.9% of the time. Results support the need to educate the clinical care staff on the importance of documenting patient weights as an indicator of nutritional status in order to improve outcomes in malnourished and at-risk patients.