Here are 7 essential tips to writing perfect PES statements and nutrition assessments that will help you make sure you’re getting them right every time.
Write Perfect PES Statements and Nutrition Assessments
When you’re starting out in nutrition, it’s so easy to feel overwhelmed by the amount of information you’re constantly asked to learn and remember.
Writing PES statements can feel like you’re learning a new language. And depending on who’s reviewing your work, writing the nutrition assessments and assessment summaries can make you feel like you never even went to school for nutrition.
This is exactly where this list of tips for writing better PES statements and doing better nutrition documentation comes in.
These seven recommendations will have you not only writing better assessments, but being able to move through patient care faster and more easily.
7 Tips to the perfect PES statement and better nutrition assessments
There’s a lot to remember when learning how to write perfect PES statements and nutrition assessments that make sense (and your preceptors love).
To cut down on the amount of time you spend writing your notes, it’s essential to have a few tricks up your sleeve. All RDs do, even if they can’t explain them to you.
That’s what we’re talking about in this post.
We’re going to talk about 7 essential tips that will make this writing process not only easier but improve the PES statements and nutrition assessments you’re putting into the EMR.
These 7 essential tips include:
- Get to the point
- Reuse and recycle content
- Choosing the problem
- Identifying the etiology
- Stating the symptoms
- Citing your sources
- Use a format
Let’s get into it.
7 Essential Tips for Better Nutrition Documentation
This list will get you started writing perfect PES statements and improved nutrition assessments.
#1: Get to the point
When writing your nutrition assessment notes, it’s essential to remember that you’re not writing an academic paper. You’re documenting only the necessary points relevant to your patient.
This means you’ve got to learn to be concise. Don’t use 10 words when 5 will do. Here’s an example.
DON’T SAY:
This patient appears to have edema located in both the right and left feet.
SAY INSTEAD:
Pt with B/L LE edema.
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#2: Reuse and Recycle Content
Never is there a reason to not copy words someone has already written. This isn’t to say you should be cutting and pasting another note into yours without revising and updating it to fit your patient. You should NOT be doing this.
But you also don’t have to reinvent the wheel. There’s no reason to be shy about using other people’s language or structure.
If a doctor or nurse or a social worker has already said exactly what you need to say (and they said it well) take what their words and incorporate it into your note.
Once you’ve done that, see #6 on this list for next steps.
#3: Choosing the problem (perfect PES statements part 1)
PES statements are a part of clinical life. And when it’s time to write them, make sure that the P (problem) always has a corresponding intervention. The point here is you should not choose a problem you can’t do anything about.
The problem in your PES statement should always be backed up by something you can actively monitor.
Here’s an example:
If someone is malnourished, your intervention should be related to how you’ll get them fed or improve their weight status.
#4: Identifying the etiology (perfect PES statements part 2)
The etiology is where the problem comes from, the medical conditions that have lead to the problem existing in the first place. This should come from the medical chart.
Don’t try to prove a problem exists if there’s no etiology documented in the EMR.
Sometimes you’ll find yourself with a patient who has no problem to solve and therefore, no etiology to point to. When this happens, don’t be shy about simply stating: no nutritional issues noted.
#5: Stating the symptoms (perfect PES statements part 3)
A patient’s symptoms can come from anywhere. This is where having a conversation or just visiting and laying eyes on your patient becomes an essential part of your PES statement and notes.
Use the first hand information you get from that visit to help justify why you know the problem is actually a problem.
Yes, you’ve got the etiology as evidence that the problem is technically a problem. But writing out the symptoms tells whoever reads your PES statement how that problem is showing up in your patient’s current life.
#6: Citing your sources
Reference where you found everything you’re documenting on. Include the date and the author of every note you use to justify your recommendations or back up your interventions.
Why do this? Because one day someone will ask where you found that piece of information. And when you have in your note exactly where you found it, the attention immediately shifts from what you wrote in your note, to what they know.
Sometimes the information you want to document on came from a conversation instead of a written note. That’s ok. Just write exactly that into your assessment. Something like per RN discussion goes a long way to remembering where you heard that thing you wrote.
#7: Use a formula
Don’t struggle to try and remember what you should be writing. Keep a list and follow it every time. Use a template that will keep you on track and ensure that every note you write has the same information arranged in the same order.
This isn’t a clinical requirement. But it makes finding information much easier down the road.
It also does two other things. First, it sets up an expectation that whoever reads your notes will be able to reliably find what they’re looking for. And second, you’ll always be able to recognize if you wrote that particular piece of documentation.
And That’s It!
These are the seven tips on writing the perfect PES statement and pulling together better nutrition assessments.
Use these on repeat whenever you’re documenting in clinical nutrition, and keep adding to your own list when you find tricks that work.
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