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LIBRARY Michigan $3” ‘ ' 011'“?th This is to certify that the thesis entitled THE APPLICATION OF THE PROBLEM-ORIENTED MEDICAL RECORD TO CLIENT NUTRITIONAL CARE: A SELF-INSTRUCTIONAL MODULE FOR DIETETIC STUDENTS presented by Mary Jo Katherine Morrissey has been accepted towards fulfillment of the requirements for Master of Science degree in Hung}: Nutrition Major professor i Date—é ” 7’ 0-7 639 THE APPLICATION OF THE PROBLEM-ORIENTED MEDICAL RECORD TO CLIENT NUTRITIONAL CARE: A SELF-INSTRUCTIONAL MODULE FOR DIETETIC STUDENTS BY Mary Jo Katherine Morrissey A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Food Science and Human Nutrition 1978 G3 ABSTRACT THE APPLICATION OF THE PROBLEM-ORIENTED MEDICAL RECORD TO CLIENT NUTRITIONAL CARE: A SELF-INSTRUCTIONAL MODULE FOR DIETETIC STUDENTS By Mary Jo Katherine Morrissey A review of the literature on Problem-Oriented Medical Records (POMR) revealed that students in the health professions (1) learn opti- mal organization of medical care through use of the POMR, (2) prefer the self-instructional approach to learning and (3) that self-instructional materials on POMR specifically for dietetic students could not be iden- tified or located. Therefore, a current self-instructional module on POMR needed to be developed for the dietetic student. A module teaching POMR was developed according to the Hiob Model (1977), an approach to Instructional design. The design of the study to test the effectiveness of the module involved a comparison of a lecture and module treatment in learning the application of the POMR Concept to client nutritional care by comparing posttest results. Diete- tic students involved in this study included twenty Coordinated Study Plan Students at Michigan State University (MSU), twelve Conventional Study Plan Students at MSU in the lecture and module groups and Mary Jo Katherine Morrissey fifteen Conventional Study Plan Students at another University to test the general utility of the module. No significant difference between the lecture and module treat- ments was found. Dietetic students tested at the other university did not show a significant difference on their posttest scores compared to the MSU Dietetic Students. The goal of achievement of ninety percent on the posttest was achieved by a majority of all the students. All groups (module and lecture) had a significant gain from pretest to posttest indicating that learning did take place. ACKNOWLEDGMENTS I wish to thank the members of the graduate committee for their support. Special thanks go to my major professor, Burness Wenberg, for her time and interest in planning my course work and thesis study. Members of my graduate committee, Dr. Wanda Chenoweth, Dr. Alice Spangler and Dr. Stephen Yelon, also gave me much encouragement and direction during this endeavor. Recognition is also due to Mr. Frank Hiob, a doctoral student in Instructional Development, for his encouragement and assistance in development of the self-instructional module. Personal thanks go to my husband, Michael, for his photography work and support in completing this study. Thanks also go to Mrs. Frances Price, Mrs. Jane Allendorph and Ms. Margo Hodder (Clinical Instructors in Dietetics) for reviewing the self-instructional module and giving helpful advice for revision of the module. Finally, special acknowledgment is given to the Michigan State University Dietetic Students in the Coordinated and Conventional Study Plans and the University of Hawaii Dietetic Students for their invaluable help in completing this project. ii LIST OF TABLES . LIST OF FIGURES Chapter I. INTRODUCTION Medical Records . Medical Records in Education of Health Professionals . TABLE OF CONTENTS Medical Students Nursing Students Dietetic Students . Implications for Dietetic Students II. RELATED LITERATURE Introduction to Individualized Instruction Historical Overview . Modular Instruction . . Kurtz and Klingstedt Model . Instructional Objective . Step 1: Step 2: Step 3: Step 4: Step 5: Step 6: Step 7: Hiob Model Step Step Step Step Step Step Step Summary . noun-nonop- Instructional Sequence 3. Procedural Approach b. Hierarchical Approach Diagnostic Measures . Rationale for the Module Instructional Activities Posttest . Resource Center . iii : Specify Learning Outcomes . : Analyze Learning Outcomes . : Criterion-Referenced Tests : Plan Lesson(s) : Construct Lesson(s) : Evaluation : Revision Page vi cocoa->4:- 10 10 10 12 14 14 16 16 17 17 18 18 19 19 19 19 21 21 22 22 22 23 23 Chapter III. PURPOSE, GOAL AND HYPOTHESES . Purpose Goal of the Self— Instructional Module Hypotheses . IV. DESIGN OF THE STUDY . . Selection of the Sample Design of the POMR Module . Step 1: Specify Learning Outcomes Step 2: Analyze Learning Outcomes Step 3: Criterion-Referenced Tests . Step 4: Plan Lesson(s) Step 5: Construct Lesson(s) Step 6: Evaluation . Experimental Design . Independent Variables Dependent Variables Analysis of Data . . . Limitations of the Study . V. RESULTS/DISCUSSION . Results of Hypothesis Testing Hypothesis A . . . Hypothesis B . Hypothesis C . . Reliability of Posttest Evaluators . Comments . VI. CONCLUSIONS/RECOMMENDATIONS Conclusions . . . . . . . . . Recommendations . . . . . . . BIBLIOGRAPHY . APPENDICES Appendix A. Performance Criteria for Learning Outcome . 8- Module Pretest and Posttest . iv Page 25 25 25 26 28 28 29 3O 30 31 33 33 34 36 37 37 37 38 39 41 41 41 43 46 48 49 49 51 52 55 59 Table LIST OF TABLES Page Results of T-test for Difference Between Pretest and Posttest Percentage Mean Scores in Lecture and Module Treatments for Michigan State University and the University of Hawaii Dietetic Students . . . . . . . 42 Independent T-test for Difference in Pretest and Difference in Posttest Percentage Mean Scores Between Lecture and Module Treatments for Michigan State Univer- sity Coordinated (Coord.) and Conventional (Conv.) Study Plan Students . . . . . . . . . . . . . . . . . . . . . 44 Independent T-test for Difference in Pretest and Differ- ence in Posttest Percentage Mean Scores in Module Treat— ment for Michigan State University Coordinated (Coord.) and Conventional (Conv.) Study Plan Dietetic Students and the University of Hawaii Conventional (Hawaii Conv.) Study Plan Students . . . . . . . . . . . . . . . 45 Number of Dietetic Students in Lecture and Module Treat- ments of Conventional and Coordinated Study Plans at Michigan State University and the University of Hawaii Achieving Ninety Percent on the Posttest . . . . . . . . 47 Performance Criteria for Learning Outcome . . . . . . . . 55 LIST OF FIGURES Figure Page 1. A Systematic Approach for Module Design: the MSU Dietetic Model (Hiob, F.: Unpublished manuscript, Michigan State University, 1978) . . . . . . . . . . . . 20 2. Cognitive Map for the POMR Module . . . . . . . . . . . . 32 vi CHAPTER I INTRODUCTION Medical Records Communication in health care settings concerning clients can be expressed most usefully to health care providers through the medical record. This record is actually an historical document in that it con- tains present and past information concerning an individual. The medi- cal record can be used in a court of law in connection with contested health care so is considered a legal document (Mason et al., 1977). According to Weed (1969), the development and proper management of the medical record should be exposed to critical assessment by peers in the same way that scientific investigations are open to the evalu- ation of other scientists. Mason et a1. (1977) stated that "the traditional medical record has been used in American Health Care institutions for at least half a century" (p. 74). This traditional medical record is referred to as the Source—Oriented Record (SOR). The SOR is the kind of record with which most health professionals are all familiar (Easton, 1974). There is a place for everything about the client. In many hospitals the system for the SOR involves identifying color-coded pages with tabs noting the location where the information can be fbund. The organization then is based on the source of information obtained throughout the provision of health care. Each person reading the SOR must mentally hold and sort data about the client from a variety of sources rather than focusing on the client's problems. Important observations by health care pro- viders could be lost or taken out of context (Mason et al., 1977). Lawrence Weed (1971) states that two fundamentals in working effectively at the community level are deve10ping communication systems that are practical for use in caring for people and establishing stan- dards for such a system so that problems and progress can be stated correctly. Weed (1971), credited with developing the concept of the Problem-Oriented Medical Record (POMR) emphasizes the point that good patient care depends upon the education of those involved in the care, and to a large degree education depends upon good records. He has highlighted the medical record as a teaching document that should enable the physician to learn while he cares for the patient. Therefore, Weed (1971) feels that the medical record need not be a static document of medical observations and activities grouped in the meaningless order of source. Rather, medical observations and activities of the client should be ordered with respect to the client's problems to which they pertain. The medical record can be problem-oriented and can be a struc- tured, creative tool for facilitating comprehensive and highly spe- cialized care. Hurst and Walker (1972) state that the Problem-Oriented format will not solve all of the problems in approaching patient care and education, but feel that it is a system that must be looked at care- fully. The POMR is a handle that all health care providers can grasp to aid in the assessment of medical care. Hurst and Walker (1972) support the guidelines set forth by Weed (1972) for POMR use. Weed (1972) suggests that the medical record reveal an identifiable Data Base from which a Complete Problem List should evolve. The problems on the Problem List are identified by title and number. The Problem List, placed in front of the medical record, is easily read by all pro- viders. An Initial Plan should be developed for each problem appro- priately identified by number and title. Progress Notes must be written in the same format. This record structure must be adhered to and will in no way interfere with the delivery of care. It is the framework from which excellence can be achieved (Weed, 1972). The American Hospital Association (1976) states that POMR is an approach to medical record keeping organized around each client's health problems. All professionals caring for the client deal with identified problems and contribute plans for each problem. The inte- gration of care provided to the individual client by each professional discipline is facilitated through regular and systematic recording in the client's medical record of care given. Such documentation must include pertinent findings and actions taken, client's progress and response to therapy, and concluding instructions of the client and/or family on physical activity, medication, diet and follow-up care. The client's medical record is an information sharing-tool that promotes and assists in coordinating the activities of all health team members contributing to the client's care. Medical Records in Education of Health Professionals Medical Students Attempts to have medical students and practitioners learn the POMR Concept have been varied. In an attempt to put a systematic approach into learning about the POMR, Bashook et a1. (1975) devised instructional materials to be used in two instructional formats: self- instruction and workshop. The majority of medical students in these two medical schools received the traditional instructional methods of lecture, laboratory and clerkship experience. One hundred and six medical students from the second year classes of these two medical schools were divided into two groups. Within each group, the students were divided again into two groups with one section of the group learning about POMR through use of a self-instructional handbook and the other section learning about POMR by attending a workshop. Students participating in each inStructional format received the same case material, overview sessions, written description of essential concepts and examples of the mechanics of problem orientation. The only dif- ference in instructional format was the use of workshop versus a self- instructional handbook. Each instructional approach extended over the same four week period. In the fifth week all the students received a SOR to convert to a POMR format. The converted record measured their performance. Within all the groups tested, there was a 95 percent performance level on this conversion from SOR to POMR. These authors report they have taught the POMR to more than twenty-five groups of practicing physicians as well as medical students using the same instructional materials. Affective feelings toward these teaching sessions have shown that physicians prefer the workshOp format because they seem to like repeated stimulation in learning a new technique that is provided on a constant interchange during a workshop session. Medical students, in direct contrast to practitioners, seemed to prefer the self-instructional format. Another study, conducted by Margolis et a1. (1976), on POMR was a workshop with twenty-three members of the Ambulatory Pediatric Association. The goal of the workshop was to help the participants learn not only how to write a problem list and problem-oriented notes, but also how to approach the practical problem of converting their medical records to a problem-oriented system. The workshop involved use of a pretest, up to three hours spent on going through self- instructional materials on POMR and a posttest which was parallel but not identical to the pretest. Both tests had two parts, (a) assessment of basic knowledge about the POMR and (b) problems requiring the use of this knowledge. Criteria for scoring were developed in advance and each test paper was graded by each of three medical staff members. A T-test was statistically significant. Several individuals scored close to zero on the pretest and close to the top on the posttest. One scored lower on the posttest than on the pretest and several remained at about the same level on the posttest. These results show that although the self-instructional format was an effective learning device fer the group as a whole, learning was not guaranteed for each indi- vidual. Possibly with repeated use of self-instructional materials on POMR, more of these students could master the POMR concept. Nursing Students Modifying and applying Weed's (1972) basic concepts to nursing has outstanding advantages (Walter et al., 1976). It is a guide to organizing care around the patient's needs. It provides a systematic method of problem-solving and decision-making. It does this and yet allows the practitioner the freedom to make independent nursing judg- ments about problems and actions. The primary focus of nursing's unique contribution to health care is the impact of health-related issues and problems on client life-style and their management of the demands of daily living. Various studies have been conducted with teaching the POMR con- cept in nursing. Bertucci et al. (1974) compared traditional and problem-oriented recording in medical records of registered nurses. In their study, nurses in the POMR and traditional group were given patient situations typical of hospitalized medical-surgical patients. They were instructed to write a nurse's note from the case material. Notes were scored on the basis of inclusion of Subjective and Objective Data, Assessment, Direct and Indirect Intervention and Plans. Mean overall scores for nurses in the problem-oriented group were significantly greater than in the traditional group as were the mean scores for inclu- sion of each portion of the format. ‘ Mitchell and Atwood (1975), conducted a study with 16S sophomore nursing students in one baccalaureate program. These students were divided into two groups. One group was taught and used traditional narrative recording and the other group used problem-oriented recording. All other content related to the basic problem-solving process was the same for both groups. Both groups were taught to record data, con- clusions, actions and evaluations relative to any one patient problem together. In theory, only the structured format of recording varied. Variables such as instructor's experience, existing use of the problem- oriented format by some physicians, student academic achievement, type of patient population were matched between groups in an attempt to control their influence. Dependent variables studied included the num- ber of problems identified, number of problems of nursing, medical and procedural focus and a score representing the quality of organization of the progress note. Medical, nursing and procedural focus refers to whether the patient problem was judged within the primary focus of nursing (daily living), medicine (pathology) or related to a therapeutic procedure (e.g., irrigation). Quality of organization scores reflected the recording of components of problem-solving from the data collection stage through evaluation of action. It was predicted that the experi- mental group would be superior to the control group by (1) identifying more problems (2) identifying more problems of nursing focus (while the control group would identify a higher proportion of problems within the medical and procedural foci) (3) identify more potential problems and incorporate plans and actions more frequently. The results were as predicted in all but one hypothesis: there was no difference in the mean number of potential problems in each group. A score was derived from the sum of problem scores for each recording sample. The significantly higher mean scores of the experi- mental group for identifying more problems, identifying more problems of nursing focus and incorporating plans and actions more frequently does reflect the large number of problems carried to the level of plan, action and in the case of some students, evaluation. Dietetic Students There are several openings in the POMR format in which the dietitian/nutritionist might participate. Diagnostic, treatment, and client education plans can all be used by the dietitian in dietary treatment of the client and progress notes revolving about the nutri- tional aspects of the case can and should be written (Voytovich, 1973). Walters and DeMarco (1973) state that the POMR should be used by the dietitian/nutritionist as a documentation process and as a procedure for evaluating dietary treatment. If the prescribed dietary treatment is less than optimal for the client, then her role is that of identi- fying the "problem" for the physician on the client's medical record. In the Dietetic Coordinated Undergraduate Program at the Univer- sity of Alabama, it was decided to incorporate the POMR concept into the dietetic curriculum. A self-instructional unit on the POMR was prepared for these dietetic students which consisted of readings on the POMR. There were no pretests or posttests included in the unit to measure learning and no available data as to whether or not this unit success- fully assisted the dietetic student in using the POMR (Stitt, 1974). Implications for Dietetic Students From the literature cited, it can be derived that students in the health professions (I) learn optimal organization of medical care through use of the POMR, (2) prefer the self-instructional format for learning and (3) dietetic students need to be able to communicate nutritional information in an equivalent manner. This thesis study was designed to develop and test a self- instructional unit on the POMR Concept as related to the dietitian's use in recording nutritional care. CHAPTER II RELATED LITERATURE Introduction to Individualized Instruction In recent years there has been an increased interest in individualized instruction, to make it the fastest growing movement in education today (Gross, 1976; Novak, 1973). The interest is based on the realization that each individual is unique and learns in ways and at a rate different to others. What is needed is instructional sys- tems which Can make higher education available to large numbers of students and at the same time offer an individualized learning experience (Goldschmid and Goldschmid, 1973). Historical Overview An historical overview of individualized instruction was written by Klaus (1971). He discusses the alternatives to conventional instructional methods (past to present) and how they have been related to student learning. Education programs designed around concepts of individual progress and rewarded practice have had ancient usage. Stecchini reported that Socrates was greatly concerned with the individual learner and stressed importance of learner participation and self- direction and even designed an automated instructional device to help students learn good handwriting (Klaus, 1971). 10 11 One of the most widely publicized of all early attempts to provide self—directed instruction on a comprehensive scale was Wash- burne's Winnetka Plan introduced into the Winnetka, Illinois, public schools in the 19205. The basis of the Winnetka Plan was the division of instruction into units or modules each with its own aims and tests of learning progress. Text materials and workbook exercises were pre- pared for each module to permit students to study content on their own and at an individualized pace (Klaus, 1971). Pressey, in 1924, suggested a somewhat different approach to individualization. His aim was not to reduce the teaching function of classroom personnel but to enhance it by eliminating the burdens of routine drill. He developed a simple apparatus which automatically gave and scored a test and would teach informational and drill material more efficiently (Klaus, 1971). The next wave of interest in individualized instruction was stimulated by Skinner. This approach was to deve10p a method of instruction which would bring the individual learner's behavior under precise control through the use of frequent and individual reinforce- ments. An important consideration is the deve10pment of these instruc- tional materials was that every effort was made to maximize success and minimize failure. Skinner maintained that the instructional materials should be presented to students by means of a machine in order to have control over reinforcement (Klaus, 1971). Glaser, Homme and Evans quickly demonstrated that machines were not all that essential in that it was feasible to use a 'programmed textbook' to provide adequate control (Klaus, 1971). 12 Programmed instruction is regarded by many educators as a tool for classroom use (Klaus, 1971). The advantages are in producing a degree of control over the learning process that cannot be attained by a teacher. Reinforced practice can result in learning and can do so with an efficiency and effectiveness that cannot be reproduced only by communicating information to a student (Klaus, 1971). Modular Instruction Among the various systems of individualized instruction proposed so far, modular instruction combines many advantages of a number of separate instructional innovations such as performance objectives, self- pacing and frequent feedback (Goldschmid and Goldschmid, 1973). A module can be defined as a "self-contained, independent unit of a planned series of learning activities designed to help the student accomplish certain well-defined objectives" as defined by Goldschmid and Goldschmid (1973) (p. 18). While differences in definition exist, it seems to be greatly agreed that a module is an instructional package intended for self-study. Creager and Murray point out that modules range from one to a few modules placed into a traditional course, through complete courses having a sequential approach through the use of modules, to courses that offer a choice of a certain number of modules from a larger set. They predicted that in the near fUture instructional programs may be designed around modules tailored to each student's individual needs (Klaus, 1971). One purpose of modular instruction is to allow the student to proceed at his own rate. The belief that self-pacing is desirable is 13 based on the generally accepted assumptions that learners do not learn at the same rate and are not ready to learn at the same time (Burns, 1971). Another purpose is to allow the student to choose his own learning mode. Choice among different learning modes is desirable, if we assume that learners solve problems and learning using different techniques based on previously learned behaviors (Burns, 1971). Modu- lar instruction may therefore include a large variety of instructional activities, such as reading textbooks and articles, examining photo— graphs and diagrams, viewing films and slides, listening to audiotapes, examining demonstration materials, participating in relevant "extra curricular" activities. A third purpose of modular instruction is to provide a choice among a large variety of tOpics within any given "course" or discipline, if we assume that students do not possess the same pattern of interest and are not motivated to achieve the same goals (Burns, 1971). A fourth purpose, according to Klingstedt, is to allow the student to identify his strengths and weaknesses and to "recycle” through remedial modules, have repetition, or a change in learning mode, if we assume that modular instruction saves student time and allows as many students as possible to attain the stated objectives (Goldschmid and Goldschmid, 1973). Finally, a module should only be produced for content areas that will not be having significant changes each year since a great deal of time is spent in design and production of the module (Goldschmid and Goldschmid, 1973). 14 Kurtz and Klingstedt Model Kurtz and Klingstedt have independently recommended a number of steps to be followed when designing a module and/or modularizing an entire course. Their steps include writing objectives, developing a sequence of instruction, designing tests, developing a rationale for the module, designing instructional activities, and establishing a resource center for readings and materials necessary to complete the module (Goldschmid and Goldschmid, 1973). This model may be summarized as follows: Step 1: Instructional Objective The instructional objective may be written in terms of behavior. Mager, in 1962, states that a behavioral objective was a collection of words or symbols describing an educational intent. An objective would communicate intent to the degree described in what the learner will know when the objective is being demonstrated. This behavioral objec- tive contained the following items: (a) identification of the overall behavioral act (b) conditions under which the behavior occurs and (c) criterion of acceptable performance (Mager, 1962). A look at current literature indicates that a turning point may be at hand with regard to behavioral objectives. There now appears to be more concern for exploring ways of redirecting the behavioral objective drive of recent years (McAshan, 1977; Dressel, 1977; Williams, 1977). Most educators would agree that both process and content are important as educational outcomes. A force that may cause a change has its origin in the performance difference between education and 15 training. Education is often thought of as a preparation for rewarding living in the all-encompassing sense, while training usually is per- ceived in terms of more definable objectives. These attempts at writing the more profound educational outcomes have been less frequent and per- haps less satisfying than have attempts at writing training objectives. Another force for redirecting behavioral objectives involves the relationship between objectives and human motivation. Many published lists of behavioral objectives appear to have little motiva- tionally based organization. As a result the student may have difficulty at a personal level with such objectives. The accountability movement represents another force affecting behavioral objectives. The issue revolved around what learning outcomes students, teachers and administrators should be accountable for. The political ramifications of accountability may require expanding the capacity of behavioral objectives to deal with all types of learning outcomes. Dressel (1977) states that objectives need to cover overt and covert learning of students. Nonverbal covert mental processes are not measured because no observable product is seen, thus eliminating thought, judgment, feeling, creating and synthesizing, except as these are ultimately verbalized or revealed by an observable product. The failure of behavioral objectives is seen when a total definition of behavior is used (including covert and overt aspects) that more nearly matches reality (McAshan, 1977). A new concept being introduced is learning outcomes. They are the ends for which all enabling instructional activities are performed. 16 These learning outcomes are the prime purposes of education. All other components of the instructional program such as the enabling strategies and evaluation processes are merely means for producing learning outcomes or for evaluating successful achievement of learning outcomes. Gagne (1970) states it this way: What is learned is something new that remains a part of the learner. These are capabilities of the learner that are the outcomes of learning. Step_2: Instructional Sequence To determine the optimal sequence of a stated competency it is necessary to carry out an analysis of that competence. Of particular interest is an analysis of the knowledge required of the learner, especially if the knowledge required is of a higher cognitive level and not merely of the memory type (Gagne, 1970). a. Procedural Approach.--The particular approaches chosen for an instructional sequence will depend upon the kind of learning required in the instructional goal. One type of approach is the procedural approach. This involves doing a task description and task analysis (Davis, Alexander and Yelon, 1974). A task description identifies the steps (or actions) that must be taken to perform a task. These actions are always stated in the form of explicit and concrete action verbs such as explains, asks, lifts, calls, etc. The task analysis literally is an analysis of the task. It helps to clarify under which circum- stances a task is to be performed. For example, what skills and abili- ties need to be known, and what resources are available to teach the task. 17 Gagne has demonstrated that inadequate treatment of some necessary skills frequently causes instruction to fail. Gagne's theory (1970) predicts that if a student has not mastered necessary prerequisite behaviors, either he will be unable to perform the termi- nal behavior, or he will do so with great difficulty. This thesis is not revolutionary--it has been assumed that students must be able to master the basic skills before they advance to more complex tasks. What is new about the theory is the procedure Gagne uses to identify the prerequisite behaviors. b. Hierarchical Approach.--This method, which follows a hier- archy to sequence instruction, identifies the elements which should be included in an effective instructional unit (Haynes, 1971). Gagne stresses that a hierarchy is composed of capabilities which are intellectual skills (cognitive strategies), and he has stressed equally that hierarchies are not composed of entities of verbalizable knowledge, such as "the student should be able to list at least seven types of supporting material." The achievement of objec- tives of verbalizable knowledge involves a certain sequence but it is not the same kind of sequence as that involved in cognitive skill acquisition, where each higher skill is dependent on certain subordinate skills. Because mastery of the terminal behavior is dependent on pre- vious mastery of each of these skills, they can be considered the beginning of a hierarchy. Step 3: Diagnostic Measures Educational measurement historically has been norm-referenced. That is, the performance of an individual learner is compared with the 18 performance of other learners to determine how much has been acquired. The newer type of tests being devised to assess instructional outcomes, particularly in individualized settings, are criterion-referenced. In contrast to norm-referenced measures, criterion-referenced tests com- pare the performance of an individual with some external absolute standard (Klaus, 1971). A very flexible definition of a criterion-referenced test has been proposed by Glaser and Nitko (1971): " . . . a test that is deli- berately constructed so as to yield measurements that are directly interpretable in terms of specific performance standards" (p. 653). According to Glaser and Nitko (1971), the performance standards are usually specified by defining some domain of tasks that the student should perform. Represen- tative samples of tasks from this domain are organized into a test. Measurements are taken and are used to make a statement about the performance of each individual relative to that domain (p. 653). Step 4: Rationale for the Module A rationale for the module is stated. This involves the value of a particular unit and explains to the student why it is beneficial to him to achieve the stated objectives. Step 5: Instructional Activities These activities are designed to help the student acquire the competencies stated in the objectives. They may include the use of laboratories, viewing of slides or films, the listening of tapes, etc. 19 Step 6: Posttest A posttest is designed to measure the student's achievement of the objectives. There should be close correlation between test items and objectives. Step 7: Resource Center A resource center should be established to provide access to all readings and/or materials necessary to complete the module. Hiob Model The trend toward individualization has resulted in the develop- ment of a diverse collection of alternative models. The model used for this study is A Systematic Program for Module Design: The MSU Dietetic Model (Hiob, 1978). This model is a general systems approach model for designing instructional materials. Each component of the model is based upon theoretical or research outcomes which demonstrate the effectiveness of the component. The steps of this model are graphically presented in Figure 1. These seven steps to the Hiob (1978) Model were used to develop the self-instructional module on the application of the POMR Concept to Client Nutritional Care. The model uses various steps discussed in this chapter in the Kurtz and Klingstedt Model (Goldschmid and Goldschmid, 1973). A description of each step follows: Step 1: Specify Learning Outcomes The learning outcome is a statement which indicates what it is students will be able to do after they have completed the lessons of 2C) .nmeau .xuumuusuca madam cemwzowz .unwuumscee nozmwapsacz ".m .nofimv .gmpo: uwuouo«o am: och "cmwmoa o~=vox now nuanced uwuasoumxm < .~ ousumm i; omoxuox h noum ovsuwuuu - umou anon n pop—602.8 . newua3~e>o unowm . umououn . macaw madam . eaves ~o>om xuuco u 0:6 cu 6:0 . moscficsuou mummy moeoouso moaoouso newuu3~a>o commofi :oMue>wuos :ofiuouauo unfinuaou unanhuoa o>wueahou nonhumcoo ”cammoH ce~m no~o>oo o~x~u=< xmfiuomm c 83 m 8% e deem m Bum N 83m H 88m 21 the module. It should describe the major culminating or synthesizing behavior which results from completing the lesson. Learning outcomes are clearly specified and contain the following: 1. the performance required by the student 2. the conditions under which the student must perform 3. the minimum acceptance level of performance Step 2: Analyze Learning Outcomes This technique is according to Gagne (1970) and identifies the subordinate skills which are required for the student to achieve the learning outcome. By asking the question, "What does the student have to know or be able to do, so that simply given instruction, he can per- form the required task?" the designer can identify one or more critical subordinate skills which will be required of the learner prior to attempting instruction of the final task. As all the subordinate skills of the final learning outcome are developed, they can be placed into a vertical map leading to the final learning outcome. Step 3: Criterion-Referenced Tests There are basically four kinds of criterion-referenced tests used in this model. The first is an entry test. This test is designed to measure skills which the designed has identified as being critical to beginning the instructional materials. The second type of test is a pretest. A pretest is criterion-referenced to objectives which the designer intends to teach in the module. The third and most common test used is the posttest. The fourth type of test is an embedded test. This is not necessarily a single test, but rather represents clusters 22 of criterion-referenced test items which are interspersed throughout the instructional package. These items are intended for practice by students prior to taking the posttest. Embedded test items provide learners with the opportunity to interact with material presented to evaluate themselves and to receive feedback. Steps 4 and 5: Plan and Construct Lessons Instructional strategies are developed for presenting infor- mation to the student in each lesson of the module, including student participation, testing and feedback. When constructing the lessons of the module, an apprOpriate form of media selection is used that is Operable by the learner and capable of being produced by the designer. Step 6: Evaluation Testing of the module can involve three types: 1. Formative (a) one to one (b) small group 2. Summative (a) field In the one to one testing the designer chooses three learners who are typical of the target papulation for the module and sits indi- vidually at each learner's side as each learner goes through the module. The designer encourages the student to comment on any aspect of the materials and makes revisions on the spot. After the materials have been revised on the basis of information from the one to one 23 evaluation, a group of approximately five to eight randomly selected learners is selected which is again from the target population. It is explained to this group of learners that the module is in a formative stage of development and the developer is seeking feedback from the learners on how the module can be improved. Then, the learners work with as little intervention as possible and give feedback at the com- pletion of work. The field evaluation involves a group of approximately twenty learners who will complete the module following written or ver— bal instructions of the module. Evaluation of the learner will be done in the form of the posttest. There are numerous models and checklists for product development processes. All models strongly advocate the use of formative evaluation as stated by Baker and Alkin (1973): . at the core of each model, regardless of its esotericism or practicality, is the realization and recognition that product deveIOpment and formative evaluation are intertwined as snake and staff and that product revision depends upon the generation of formative evaluation of data (p. 404). Step 7: Revision Revision of the module is based on learner feedback and achieve- ment of the learning outcome(s). By utilizing all the student sug- gestions and performance during the evaluations, the module can then be made into a final professional product. Summary Many forms of individualized instruction have been discussed here. Throughout time, various people have been innovative in deve- loping individualized instructional methods for learners. 24 The Hiob Model (1978) for modularized instruction incorporates the majority of concepts reported in the current literature: criterion- referenced tests, learning outcomes and the performance of formative evaluation. For these reasons the Hiob Model (1978) was used for this study instead of the Kurtz and Klingstedt Model (Goldschmid and Goldschmid, 1973). Further, the Hiob Model (1978) was used in order to aid in the validation of it for use with learning skills at the cognitive level. CHAPTER III PURPOSE, GOAL AND HYPOTHESES Purpose A self-instructional module on the Problem-Oriented Medical Record (POMR) was developed for dietetic students because a review of the literature has shown that (1) there were no available materials on POMR specifically for the dietetic student and (2) self-instruction is the preferred approach. The purpose of this module was to develop a concise method for learning the application of the POMR Concept to client nutritional care through the use of dietetic problems, plans of action for client behavior and SOAP progress notes of nutritional care implementation. Goal of the Self-Instructional Module It was determined that an achievement level of ninety percent accuracy on the module posttest would indicate that the dietetic student had demonstrated the application of the POMR Concept to client nutritional care. The level of ninety percent was chosen because dietetic students need to easily apply the POMR process to client nutritional care in their first entry-level position as a dietitian. Reaching ninety percent on the posttest, which would be compared to above average performance, would increase the probability of transfer of learning of the POMR process for use with future nutritional clients. 25 26 After completing the self-instructional module on the POMR, the dietetic student should be able to achieve a ninety percent level of accuracy on the posttest covering the following areas: 1. 2. Dietetic Problems--concise statement of food or nutritional problem of the client Plan of Action for Client Behavior--initial plan for client care including diagnostic, therapeutic and client education sections SOAP Progress Note of Nutritional Care Implementation--recording of progress of the client in solving his/her dietetic problem written in the SOAP format Hypotheses Given the goal of the self-instructional module on POMR, the following hypotheses were written. A. B. Null Hypothesis: Dietetic students at MSU and the University of Hawaii given a self-instructional module or equivalent lecture presentation to learn the application of the POMR concept to client nutritional care will show no significant gain in score from pretest to posttest (both tests measuring equivalent content) to indicate that learning has taken place. Alternative Hypothesis: Null Hypothesis: Dietetic students at MSU and the University of Hawaii given a self-instructional module or equivalent lecture presentation to learn the application of the POMR concept to client nutritional care will show a significant gain in score from pretest to posttest (both tests measuring equivalent content) to indicate that learning has taken place. Dietetic students at MSU given a self-instruc- tional module to learn the application of the POMR concept to client nutritional care will show no significant difference in achievement on the posttest compared to dietetic students given an equivalent lecture presentation to learn the application of the POMR concept to client nutritional care and same posttest. 27 Alternative Hypothesis: Dietetic students at MSU given a self-instruc- tional module to learn the application of the POMR concept to client nutritional care will show a significant difference in achievement on the posttest compared to dietetic students given an equivalent lecture presentation to learn the application of the POMR concept to client nutritional care and same posttest. It was further hypothesized that the POMR module would be useful to dietetic students at other universities. In order to have instruc- tional materials useful for a variety of dietetic curriculums, the module's design needs to be learned and applied in an equivalent manner by other dietetic students. The POMR module was tested with dietetic students at the University of Hawaii and their posttest results were compared with Michigan State University dietetic students. This approach is written in Hypothesis C. C. Null Hypothesis: Dietetic students at MSU given a self-instruc- tional module to learn the application of the POMR Concept to client nutritional care will show a significant difference in achievement on the posttest compared to dietetic students at the University of Hawaii given the same self-instructional module to learn the appli- cation of the POMR Concept to client nutri- tional care and same posttest. Alternative Hypothesis: Dietetic students at MSU given a self-instruc- tional module to learn the application of the POMR Concept to client nutritional care will not show a significant difference in achieve- ment on the posttest compared to dietetic students at the University of Hawaii given the same self-instructional module to learn the application of the POMR Concept to client nutritional care and same posttest. CHAPTER IV DESIGN OF THE STUDY Selection of the Sample To be eligible to be in this study, dietetic students needed to have completed certain prerequisites. These included completion of HNF 102 - Nutrition for Man, HNF 221 - Food and the Consumer and HNF 222 — Laboratory for Food Management. Before starting the module or attending the lecture, the dietetic student was required to read the Medical Record Chapter from the Dynamics of Clinical Dietetics textbook (Mason et al., 1977). During Fall Term 1977, the designer worked with the Clinical Faculty of the Coordinated Study Plan at MSU to determine which of the student groups would be used for this study. HNF 302 for the Coordi- nated Study Plan had twenty students enrolled and the concept of the medical record was to be taught in Winter Term 1978. Thus, the designer had twenty non-volunteers for part of the study. These students would receive a grade for their performance on the posttest and knew that they would have an immediate application of this POMR knowledge in their clinical field experiences. In following this thesis study design, a comparison lecture group was needed. So ten of these twenty Coordinated Study Plan Dietetic Students were randomly assigned to the module group and ten randomly assigned to the lecture group. 28 29 Dietetic students in the Conventional Study Plan who partici- pated in this study were selected Winter Term 1978. The designer obtained volunteers from various nutrition classes being taught winter term. Upon obtaining twenty volunteers, they were randomly assigned (10 and 10) to the lecture and module groups. These students did not receive a grade on their performance on the posttest and overall were not having an immediate application of this POMR knowledge in the near future. The designer had an opportunity to select dietetic students at the University of Hawaii for this study also. Fifteen students volun- teered for this study and received only the module treatment. These students were in 3 Conventional Dietetic Curriculum and were required to have completed an introductory nutrition course and introductory food preparation course. Before starting the POMR module, these University of Hawaii dietetic students were required to read the Medical Record Chapter from the Dynamics of Clinical Dietetics textbook (Mason et al., 1977). The University of Hawaii dietetic students did not receive a grade for their performance on the posttest and overall were not going to have an immediate application of this POMR knowledge in the near future. Desigp of the POMR Module The seven steps of A Systematic Model for Module Design: the MSU Dietetic Model (Hiob, 1978) were used to develop the self-instruc- tional module on the application of the POMR Concept to client nutri- tional care. A detailed description of each step follows: 30 Step 1: Specify Learning Outcomes The learning outcome for the POMR Module is: Given nutritional information about a client, the student dietitian will write the dietetic problem, plan of action and SOAP progress note with ninety percent accuracy according to the performance criteria. In order to evaluate this learning outcome, performance criteria were developed for the posttest. These criteria pertain to writing dietetic problems, plans of action and SOAP progress notes, and are a total of one-hundred points. They can be found in Table A-1 of Appendix A. Step 2: Analyze LearningOutcomes After the learning outcome was determined, the designer deter- mined the subordinate skills necessary for achievement of the final learning outcome. Subordinate skills leading to the final learning outcome were arranged in the following hierarchy. l. Discriminate between the dietetic problem categories 2. Identify the dietetic problem categories 3. Classify the dietetic problem categories 4. Generate the dietetic problem 5. Identify the dietetic solution 6. Generate the dietetic solution 7. Identify components of the plan of action 8. Classify the plan of action 9. Generate the plan of action 10. Identify the subjective and objective information of the progress note 31 ll. Generate the subjective and objective information of the progress note 12. Generate the dietetic problem, subjective and objective infor- mation of the progress note 13. Generate the assessment of the progress note 14. Generate the dietetic problem, subjective and objective infor- mation, and assessment of the progress note 15. Generate the dietetic problem, subjective and objective infor- mation, assessment and total plan of the progress note As the subordinate skills were written, they were placed into a vertical cognitive map to show the sequence of learning to be achieved by the student (Figure 2). Steps one through four represent lesson one of the module, steps five through nine represent lesson two of the module and steps ten through fourteen represent lesson three of the module. The module starts with step one and sequentially goes through step fourteen in reaching the final learning outcome (fifteen). Pre-entry skills represent the prerequisites the student must master before entering the module. Step 3: Criterion-Referenced Tests For the POMR module, the entry behavior test and pretest were combined into one test. This test measured an assessment of basic know- ledge about the POMR and followed the hierarchy of the embedded test questions of the POMR self-instructional module. The embedded tests were interspersed through the lessons of the module and were represen- tative of the pre- and posttest questions. The posttest questions consisted of three essay questions all measuring the same criterion: dietetic problems, plans of action and SOAP progress notes using a LEARNING OUTCOME > > > > > > > > > > > Lesson I Lesson 2 Lesson 3 LPre-entry Skllls I Figure 2. Cognitive Map for POMR Module. The subordinate skills are completed sequentially (one through fourteen) in order to achieve the final learning outcome (fifteen). 33 case study approach. All of these criterion referenced tests were paper and pencil exercises. The pretest and posttest were parallel covering the same content material but used different nutritional case study characters. Each test was based on a one-hundred point grading scale. The case studies in the pretest were graded according to the same performance criteria used on the posttest. Steps 4 and 5: Plan and Construct Lessons In order to have the students motivated for high achievement in the POMR module, the designer used some techniques that would elicit positive affective feelings about the content material. Music was used on the audio tape to introduce and end each lesson and cartoon features were interspersed through the lessons. In the lessons, the designer tried to avoid the use of educational jargon and state the purpose of each lesson in words that would be understood by the students. Content information on the POMR was presented by use of a student booklet and slide tape presentation. The booklet presented the content information in short paragraphs and case studies with embedded tests used at various intervals. These test questions were written on separate sheets where the student could also record the answers. Answers to the embedded test questions were presented on slides and in the booklet. The slide tape was also used to present various types of content information. Instructions for proceeding back and forth between the booklet and slide tape were given on the slides and in the booklet. 34 One consideration for the production of a module is the ability of the designer to produce materials in a particular format. The for- mat used was the most compatible for the designer's experience with media and the resources available for the module use. The photographic slides used in the slide tape presentation were produced by use of a copystand at the Instructional Resource Center at MSU. This involved typing out word messages on 6" by 9" cards with the primary typewriter to fit within the lens dimensions of the camera. A storyboard was used in deciding on the types of slides and corresponding script to be used. The audiotape was recorded by use of a Wollensack tape recorder and stereo music was interspersed at the appropriate times (according to the script) with mixing techniques. The slides were syn- chronized to the tape so that the student would not have to advance the slides manually. The student booklet had various kinds of type styles used in it to draw attention to specifics, e.g., italic type was used for directions for the student and various concepts being presented. Testing of the POMR module was conducted in the Dietetic Instruc- tional Resource Center in the Human Ecology Building. This resource center is equipped with study carrels providing audio playback tape units, slide carousels and earphones. Each student going through the module could sit at a separate carrel with very few distractions. Step 6: Evaluation Before doing the final testing of the module, a formative evaluation was conducted. Formative specifically expresses that it is in the developmental process toward an appropriately sequenced final product. 35 First of all, a one-to-one formative evaluation was conducted. Three dietetic students representative of the target population sat independently side-by-side with the designer and went through each step of the module to clarify it and correct any misunderstandings. Changes were made as the student went through it. In the small group formative evaluation, seven dietetic students representative of the target population went through the module inde- pendently and gave feedback to the deveIOper. Changes were made in the module after this evaluation also and then the module was ready for final testing which is termed summative evaluation. The lecture was given by a Registered Dietitian who was shown the pretest and posttest questions in advance of giving the lecture in order to develop a lecture with a similar sequence as the module. Further consultation was given to the lecturer from the designer as was needed. Both the lecture and module were kept at a two hour time limit. Self-instructional materials are usually self-paced but since the lec- ture treatment had a two hour time limit, the same time limit was used with the module treatment. An equal time limit was used for both treatments. The pretest was completed to familiarize the student with the concepts of the study and after each student completed the module or attended the lecture treatment, he/she received a glossary of terms concerning the POMR to review before completing the posttest. Because the posttest was a subjective essay test, it was evalu- ated by two Registered Dietitians according to the performance criteria. (Table A-1, Appendix A). The graduate committee of the designer advised her to use two posttest evaluators in order to ensure unbiased 36 test results. The designer was one of the evaluators plus one of the clinical instructors in the dietetic coordinated study plan at MSU. Experimental Design_ This experiment contained the following components: Hypothesis A: 1. MSU dietetic students were given the lecture and module treatments plus pretest and posttest and the University of Hawaii dietetic students were given the module treatment plus pretest and posttest. Hypothesis B: 1. MSU dietetic students were given the lecture treatment and posttest according to the type of student a. Conventional Study Plan b. Coordinated Study Plan MSU dietetic students were given the module treatment and posttest according to the type of student. a. Conventional Study Plan b. Coordinated Study Plan Hypothesis C: 1. MSU dietetic students were given the module treatment and posttest according to the type of student a. Conventional Study Plan b. Coordinated Study Plan University of Hawaii dietetic students were given the module treatment and posttest according to the type of student. a. Conventional Study Plan 37 Independent Variables Learning of the application of the POMR Concept to client nutritional care. 1. Treatment a. lecture b. self-instructional module 2. Curriculum a. MSU Dietetic Students in Conventional Study Plan b. MSU Dietetic Students in Coordinated Study Plan c. University of Hawaii Dietetic Students in Conventional Study Plan 3. University Setting a. Michigan State University b. University of Hawaii Dependent Variables Pretest of the application of the POMR concept to client nutritional care. Posttest of the application of the POMR concept to client nutritional care. Analysis of Data Two-tailed T-test at significance level of .05. Kuder-Richardson Formula used for an estimate of reliability of Rater Variance on Essay Test Scores. 38 Limitations of the Study This study has limitations which are noted. The sampling of dietetic students in each group (Coordinated Study Plan and Conventional Study Plan at MSU and Conventional Study Plan at the University of Hawaii) were both small and varied. The prerequisites of completed course work of both the MSU and the University of Hawaii dietetic students were similar but not the same. It is not known whether competency was equivalent. Amount of prior experience with mediated instruction was not determined as a component of participation, thus the module may prove more or less difficult for some students. The dietetic students at the University of Hawaii may have had different cultural backgrounds than MSU dietetic students. Varied interpretations of the instructional materials could result. The designer would be available to administer the pre and post- tests for the MSU students, but was not available for the University of Hawaii dietetic students. The comparison between the equivalent content material presented in the module and the lecture cannot definitely be determined. Some students were graded on their performance in the study whereas others were volunteers. The graded students may have been more motivated to do well. The two posttest evaluators may interpret the performance criteria differently. The lecturer is an instructor of the MSU Dietetic Coordinated Study Plan students whereas the Dietetic Conventional Study Plan students at MSU are not familiar with her. This may produce varied results on the posttest. CHAPTER V RESULTS/DISCUSSION These null hypotheses have been written: (A) dietetic students at MSU and the University of Hawaii given a self-instructional module or equivalent lecture presentation to learn the application of the POMR concept to client nutritional care will show no significant gain in score from pretest to posttest (both tests measuring equivalent content) to indicate that learning has taken place, (B) dietetic students at MSU given a self-instructional module to learn the application of the POMR concept to client nutritional care will show no significant difference in achievement on the posttest compared to dietetic students at MSU given an equivalent lecture presentation on POMR and same posttest and (C) dietetic students at MSU given a self-instructional module to learn the application of the POMR concept to client nutritional care will show a significant difference in achievement on the posttest compared to dietetic students at the University of Hawaii given the same self- instructional module and same posttest. Also an achievement at the Mastery level of ninety percent accuracy on the posttest would indicate that the dietetic student can apply Problem-Oriented Medical Record (POMR) knowledge into accurately writing a dietetic problem, plan of action and SOAP progress note. 39 40 When the hypothesis predicts that differences will exist in the data and allows this difference to be in either direction (larger or smaller), a two-tailed test of its null hypothesis is performed since the difference can fall in either tail of sampling distribution (Nie et al., 1975). The T-test provides the capability of computing whether or not the difference between two sample means is significant. Two types of tests may be performed. 1. Independent samples: the cases are classified into two groups and a test of mean differences is performed for Specific variables. 2. Paired samples: for paired observations arranged casewise, a test of treatment effects is performed. An example would be the same (or similar) individual being measured before and after treatment. The goal of the T-test statistical analysis is to establish whether or not a difference between two samples is significant. "Sig- nificant" is used to mean "indicative of" or "signifying" a true dif- ference between the two samples (Nie et al., 1975). A significance level for testing the null hypothesis was chosen and set at equal to or less than .05. This significance level is exactly the probability of rejecting the null hypothesis when it is true (Nie et al., 1975). If it is known whether the two populations have the same vari- ance, an F test of sample variances may be performed. The null hypo- thesis with alternative hypothesis and a significance level a' is chosen. An 0' level of .05 was chosen. From the sample variances, F was computed. If the probability for F is greater than a', the t value based on the pooled-variance estimate is used to determine probability. 41 If the probability for F is less than or equal to a', the t value is based on the separate variance estimate to determine probability (Nie et al., 1975). Results of Hypothesis Testing Each hypothesis is presented along with a report of findings. Five of the pretests of the Michigan State University Conventional Study Plan Dietetic Students were misplaced so the data from these students could not be included in the analysis of data. Hypothesis A: Dietetic students at MSU and the University of Hawaii given a self-instructional module or equivalent lecture presen- tation to learn the application of the POMR concept to client nutri- tional care will show no gain in score from pretest to posttest to indi- cate that learning has taken place. This hypothesis was tested using the dependent T-test. Results are reported on Table 1. Findings: The null hypothesis was not supported. There was a significant gain from pretest to posttest for all groups (a < .001). The pretest scores for both treatments showed greater deviation compared to the deviation in the posttest scores, which may also indicate that more students learned the POMR concept in an equivalent manner. 'Hypothesis B: Dietetic students at MSU receiving the self- instructional module on POMR will not show a significant difference in achievement on the posttest compared to dietetic students at MSU given an equivalent lecture presentation on POMR and same posttest. This hypothesis was tested using the independent T-test. As the dietetic curriculum had two offerings, the Coordinated Study Plan 42 .Hoo. v 6 HQ Hflmoflmwcmwwm HNn.~ mum. mmc.~ nouuo wuepnmum mmm.m~ mmm.m www.mH :ofluew>ow pudendum eSo. Hm NA.HH moom.Hm moov.mm ooom.~o awe: mmm u 2U «nave: nmw.m o~n.~ mHv.N nouuo veepceum NNN.~H Hmo.o vmm.m nowada>op pumpcmum «Hoe. ea mo.w noo~.mm mmmm.om noow.no new: Amfi u 2U ohspooq m we msfie> homepage ummupmod amoumnd means a -umouumodv oocohowmflo .munovauw ofiuouofim Manse: mo xpfimgo>fica one pee xuflmho>wcz opmum :wwflsofiz Hem mucoaueouh mauve: pew weapon; :a monoum :moz ommucoouod amouum0d paw «weaved coozuom cocoHoMMMQ now amouuh mo mufismomnu.a oaseh 43 and Conventional Study Plan, the data were collected separately for students enrolled in each plan. Results are reported on Table 2. Findings: The null hypothesis was supported. The difference in achievement on the posttest scores for the module and lecture groups was not significantly different. Further analysis revealed that the Conventional Study Plan students in the module group had the lowest standard deviation. The Coordinated Study Plan students in the module treatment may have been a more homogeneous group. The pretest scores were analyzed at the same time the posttest scores were analyzed and so were also included on Table 2. There was a significant difference in pretest scores between the lecture and module groups of the MSU Coor- dinated Study Plan students (.001) whereas pretest scores in the lecture and module treatments for the MSU Conventional Study Plan students were not significantly different. Hypothesis C: Dietetic students at Michigan State University receiving the self-instructional module on POMR will show a significant difference in achievement on the posttest compared to dietetic students at the University of Hawaii given the same self-instructional module and posttest. This hypothesis was tested using the independent T-test. As the dietetic curriculum had two offerings, the Coordinated Study Plan and Conventional Study Plan, the data were collected separately for students enrolled in each plan. Results are recorded on Table 3. Findings: The null hypothesis was not supported. The differences in achievement on the posttest percentage mean scores were not significant. 44 .pom: we: owesfiumo oocmflum> oumhmmom < .pom: was mumswumo oocmflum> pofioom < o a .8. v a a uéuumaaama wmm.m mun. wmo.m ch.~ nonuo pudendum mam.m va.m ome.v cme.o :oflumfl>op peevempm n_o.\.m. OH BH.H owmv.Hm ooov.cw omem. nm.- mH.H ooom.mm ooom.mm emoz umoppmoa mnH.e oeo.~ mnfi.m on.m uonno vampeeum Heo~.HH nom.w Nmo.n owe.o~ cofiumfi>ov pumpemum mmmm. oH vo.H Amwm.mn ooov.mo peace. ma mm.m ooom.me ooom.oo can: umououd Aenzv Aofluzv Amaze fiofiuzv .nonm mp 63Hm> .>:ou .>:ou .>:ou .vhoou Hwehuoze e amaze: am: “Haze: 2m: amok ofispoz opened; .mpcopSum dead xpaum m.>couv Hm:6wuco>:ou van m.pnoouv poumcfivhoou zuwmuo>fics oumum :mwfi:0fi2 pom mucospmohh oflspoz paw ohsuooa coozuom mohoom new: ommpcoouod umouumom a“ mucouommfio pew umouond cw mucouowmflo Mom umopuh acopcomopcmuu.m ofinmh 45 .UOWS mw3 OHMEHHmw oocwflnm> oumnmmom <0 .uom: we: oumeumo ousmwam> poHoom < n .mc. v a “a peeofimfiamuma mmm. mam.m mmm. man. tonne enmeeaum muo.m mum.m muc.m mme.~ souueasoe egaeeapm umeo. Nw.o as. ecoo.mm owme.sm UNOfl. mm oa.~ acco.mm ooom.mm cam: pmouumom awe.m mhu.v Hwa.m oee.m gonna enaeeaum eeo.eH HVO.HH evo.aH nom.w coupaasoe enaeeaum awoo. om mm.H ooo~.mo amw~.ma sense. mm HA.N ooom.mo oocm.ms emu: Hmmuvhm . flmHqu Amaze fimsuzv flouuzv pmoe noun we o=Hm> .>:ou .>:ou .>:ou .phoou Hume-oza a usage: am: amaze; am: ounce: ounce: .mucopsum :eHm xpSHm n.>:ou fifimzmmv Hm:0flpco>=ou wflmze: mo xufimuo>flca one one mucovzpm owuouofia :mHm xvaum n.>:ouv Hmcowu=o>cou pee m.phoouv poumcfiphoou xufimno>fics oumuw cmmflnoflz mom unoEpmoeh mauve: cw monoum nee: owmucoonod umoupm0d :« oucopommfin pee umopmpa :fi oocohommfio pow pmopuh ucopcomovcHuu.m ofinmh 46 Further analysis (Table 3) revealed that the pretest percentage mean scores of the Michigan State University Coordinated Study Plan students and the University of Hawaii Conventional Study Plan students were significantly different (.013). In comparing the Conventional Study Plan students at Michigan State University and the University of Hawaii Conventional Study Plan students, it is seen that neither their pretest or posttest percentage mean scores were significantly different as also seen on Table 3. The dietetic students at Michigan State University and the University of Hawaii achieving ninety percent on the posttest are recorded on Table 4. The majority of students in each group achieved the ninety percent criterion level. Reliabilipy of Posttest Evaluators The calculation of a Reliability Coefficient was used for esti- mating the reliability of the two independent evaluators of the posttest (Ebel, 1972). The formula is: anye- Zny r = ' /In2x2 - (2x)21 [an2 - (EX)2] The results of the formula indicated that the reliability coefficient was .69 indicating that the two evaluators had sixty-nine percent reliability. The score can range from zero to one with scores near one indicating high reliability between raters. 47 Table 4.--Number of Dietetic Students in Lecture and Module Treatments of Conventional and Coordinated Study Plan Students at Michigan State University and the University of Hawaii Achieving Ninety Percent on the Posttest. Number of Number of Students Treatment Students Achieving 90% on ~Posttest Lecture MSU Conventional 5 4 Coordinated lO 9 Module MSU Conventional 7 5 Coordinated 10 9 Module University of Hawaii Conventional 15 14 TOTAL 47 41 48 Comments The students' feelings (affect) regarding the module were recorded. They felt that more time was needed to be spent on the Assessment Component of the SOAP Progress Note and less time on learning about Dietetic Problems. The students felt that they derived benefit from the embedded test questions while going through the module. The affective aspects of the module (music, cartoons and statements about their success, e.g., You're Doing Fine!) were enjoyed by all of the students and recommended to be left in the module. The dietetic students at the University of Hawaii thought that the cartoons of lesson two of the module needed to be more relevant to the content. Students reported there was confusion when they had to move back and forth between the slide tape and student booklet but this confusion decreased as the student kept going through the module. Also clarity as to whether or not only one answer is acceptable for the embedded test questions is needed. Those students attending the lecture treat- ment felt that the lecture was lengthy and repetitious but that the case study examples used were helpful. The students overall felt that they learned how to write SOAP notes in the correct format. CHAPTER VI CONCLUSIONS/RECOMMENDATIONS Conclusions Major conclusions from this study concern Hypotheses A, B and C. Null Hypothesis A states that dietetic students at MSU and the University of Hawaii given a self-instructional module or equivalent lecture presentation to learn the application of the POMR concept to client nutritional care will show no gain in score from pretest to posttest (both tests measuring equivalent content) to indicate that learning has taken place. Hypothesis A was rejected since there was a significant gain in score from pretest to posttest to indicate that learning had taken place. Null Hypothesis B states that dietetic students at MSU given a self-instructional module to learn the appli- cation of the POMR concept to client nutritional care will show no significant difference in achievement on the posttest compared to dietetic students given an equivalent lecture presentation to learn the application of the POMR concept to client nutritional care and same posttest. Null Hypothesis B was accepted since there was not a significant difference in posttest percentage mean scores between the module and lecture groups in either the Coordinated Study Plan or Conventional Study Plan dietetic students at Michigan State University. Null Hypothesis C states that dietetic students at MSU given a 49 50 self-instructional module to learn the application of the POMR concept to client nutritional care will show a significant difference in achievement on the posttest compared to dietetic students at the University of Hawaii given the same self-instructional module to learn the application of the POMR concept to client nutritional care and same posttest. Null Hypothesis C was rejected since the posttest scores of the dietetic students at the University of Hawaii receiving the module treatment were not significantly different than the posttest scores of the Michigan State University dietetic students in the module groups. The University of Hawaii's dietetic students' high posttest scores may be accounted for by the fact that they were being offered an opportunity to participate in a project being offered by another large mainland university. These students could have developed interest and curiosity with a desire to perform well. Forty one of the forty seven students (93%) participating in this study were able to achieve at the ninety percent criterion level on the posttest regardless of being in the lecture or module group. Over ninety percent of the University of Hawaii dietetic students achieved ninety percent on the posttest which may indicate that the POMR module has the potential of being used with other dietetic programs with their students achieving the ninety percent criterion level on the same posttest. The raters of the posttest for all groups showed a sixty nine percent reliability coefficient between each other. The use of the performance criteria checklist used in scoring the posttests probably 51 accounted for this reliability and further clarification of the criteria may yield higher results. Recommendations A major recommendation would be that the module be revised for clearer understanding based on the comments of the students. The whole module is being reviewed by the designer's Graduate Committee Members and Clinical Faculty of the Coordinated Study Plan in Dietetics at Michigan State University in order to convert it from a prototype into a Professional Instructional Module. A self-instructional module should be produced using a content area that does not change frequently in order to have the time spent in design and production worthwhile. Evaluation of more pre- and posttests of the module with more dietetic students could be conducted to increase the validity of the module. It appears that the hierarchical process used to develop a final learning outcome (Hiob, 1978) has application for other types of cogni- tive learning in order to develop a sequential path leading the student to mastery of a subject. This thesis study has shown that the hier- archical process is successful in aiding the dietetic student in learning the application of the POMR concept to client nutritional care and, in the designer's opinion, be applied to the development of other materials in the cognitive domain in dietetic curriculums. BIBLIOGRAPHY BIBLIOGRAPHY Baker, E. and Alkin, M. Formative evaluation of instructional deve10p- ment. Audiovisual Comm. Rev. 21:4:389-418, 1973. Bashook, P. et al. Teaching problem-oriented recording: a systematic approach. J. Medical Educ. 50:10:959-64, 1975. Bertucci, M. Comparative study of problem-oriented and traditional methods of charting. Nurs. Res. 23:251-54, 1974. Burns, R. et a1. Methods for individualizing instruction. Educ. Tech. 11:6:55-56, 1971. Davis, R., Alexander, L., and Yelon, S. Learning System Design: An Approach to the Improvement of Instruction. New York: McGraw- Hill, Inc., 1974. Dressel, P. The nature and role of objectives of instruction. Educ. Tech. 15:5:7-15, 1977. Easton, R. Problem-Oriented Medical Record Concepts. New York: Appleton-Century-Crofts, 1974. Ebel, R. Essentials of Educational Measurement. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1972. Gagne, R. The Conditions of Learning. New York: Holt, Rinehart and Winston, 1970. A Glaser, R., and Nitko, A. Measurement in learning and instruction. In Thorndike, R., ed. Educational Measurement. 2nd ed. Washing- ton: American Council on Education, 1971. Goldschmid, B., and Goldschmid, M. Modular instruction in higher edu- cation: a review. Higher Educ. 2:15-32, 1973. Gross, K. Accent on Learning: Improving Instruction and Reshaping the Curriculum. lst ed. San Francisco: Jossey-Bass, 1976. Guidelines for Recording Nutritional Information in Medical Records. Chicago: Am. Hospital Assoc., 1976. 52 53 Haynes, J. Improving instruction in speech-communication skills through learning hierarchies: an application to organization. Speech Teach. 22:237-43, 1973. Hiob, F. A systematic program for module design: the MSU Dietetic Model. Unpublished manuscript, Michigan State University, 1978. Hurst, W., and Walker, H. The Problem-Oriented System. New York: Medcom, Inc., 1972. Klaus, D. Instructional Innovation and Individualization. Second Printing. Kensington, MD: American Institute for Research for the Agency for International Development. U.S. Dept. of State, 1977. Mager, R. Preparing Instructional Objectives. Palo Alto, Calif.: Fearon Publishers, Inc., 1962 Margolis, C. et al. Using a workshOp to determine the effectiveness of a text on the problem-oriented medical record. J. Med. Educ. 51:9:767-8, 1976. Mason, M. et al. The Dynamics of Clinical Dietetics. New York: John Wiley and Sons, 1977. McAshan, H. Behavioral objectives: the history and the promise. Educ. Tech. 15:5:36-44, 1977. Mitchell, P., and Atwood, J. The problem-oriented system for patient- centered care. Amer. J. of Nurs. 24:2:99-103, 1973. Nie, N. et al. Statistical Package for the Social Sciences. 2nd ed. New York: McGraw-Hill Book Co., 1975. Novak, J. The Future of Modular Instruction. Center for Improvement of Undergraduate Education. Notes No. 6. Ithaca, N.Y.: Cornell University, 1973. Stitt, K. What's new at the university: examples of clinical teaching in coordinated undergraduate programs. J, Amer. Dietet. Assn. 65:5:558, 1974. Voytovich, A. The dietitian/nutritionist and the problem-oriented medical record. J. Amer. Dietet. Assn. 63:641-43, 1973. Walter, J. et al. Dynamics of Problem-Oriented Approaches: Patient Care and Documentation. Philadelphia: J. B. Lippincott Co., 1976. Walters, F., and DeMarco, M. The dietitian/nutritionist and the problem-oriented medical record. J. Amer. Dietet. Assn. 63: 6:641-43, 1973. 54 Weed, L. Medical Records, Medical Education, and Patient Care. 5th ed. Cleveland: Case Western Reserve Univ. Press, 1969. Weed, L. The problem-oriented record. In Hurst, W., and Walker, H., eds. The Problem-Oriented System. New York: Medcom, Inc., 1972. Williams, R. A behavioral typology of education objectives for the cognitive domain. Educ. Tech. 15:6:39-46, 1977. APPENDICES APPENDIX A PERFORMANCE CRITERIA FOR LEARNING OUTCOME APPENDIX A PERFORMANCE CRITERIA FOR LEARNING OUTCOME Table A-l.--Performance Criteria for Learning Outcome. LEARNING OUTCOME: Given nutritional information about a client, the student dietitian will write the dietetic problem, plan of action and SOAP progress note with ninety percent accuracy according to the following criteria: Dietetic Problem Statement: Points (6) conciseness written in up to 6 words: 6 points written in up to 7-10 words: 4 points written in up to 11-14 words: 2 points written in greater than 14 words: 0 points (6) _______ accuracy: dietetic problem statement must have the same nutritional meaning as the possible answers given for the dietetic problem on the answer sheet Plan of Action Diagpostic Component (4) presence of diagnostic component of plan 55 Points (4) (4) or (12) (4) (4) (4) or (12) (4) (4) (4) or (12) (2) and (2) 0r (4) 56 data suitable for diagnostic category data fits nutritional information of client no diagnostic entry Therapeutic Component presence of therapeutic component of plan data suitable for therapeutic category data fits nutritional information of client no therapeutic entry (if applicable) Client Education Component presence of client education component of plan data suitable for client education entry data fits nutritional information of client no client education entry (if applicable) SOAP Progress Note Subjective Information presence of subjective entry complete and accurately classified objective infor- mation written about the client no subjective entry (if applicable) Points (2) and (2) 01‘ (4) (4) (4) (4) (4) (4) 01' (4) (4) (4) or (12) 57 Objective Information presence of objective information complete and accurately classified subjective infor- mation written about the client no objective entry (if applicable) Assessment presence of assessment accuracy of assessment based on subjective and objective information Plan of Action Diagnostic Component presence of diagnostic component of plan data suitable for diagnostic category data fits nutritional information of client no diagnostic entry Therapeutic Component presence of therapeutic component of plan data suitable for therapeutic category data fits nutritional information of client no therapeutic entry (if applicable) 58 Points Client Education Component (4) presence of client education component of plan (4) data suitable for client education entry (4) data fits nutritional information of client or (12) no client education entry (if applicable) 100 APPENDIX B MODULE PRETEST AND POSTTEST APPENDIX B MODULE PRETEST AND POSTTEST PRETEST: PROBLEM—ORIENTED MEDICAL RECORD STUDY Which of the following is pop_one of the components of the POMR? a. defined data base b. progress notes c. food intake record d. the initial plans e. complete problem list What are the three (3) sections of the Initial Plans Component of the POMR? a. b. C. Long standing food habits are more likely to be changed if: a. authority is used b. a three-day fast is initiated c. new foods are gradually added to existing food patterns d. a person feels threatened 59 5. 6. 7. 60 The elements of the Narrative Progress Notes are the Subjective (S), Objective (0), Assessment (A), and Plan (P) Categories which are abbreviated as SOAP. In this exercise match S, O, A, and P with their descriptions a. contains verifiable information such as laboratory test results contains the strategy for client education, diagnostic and therapeutic procedures an analysis of the problem based on both Subjective and Objective data the client's perception of the Problem Which of the following is a component of the POMR? a. b. source-orientation nutritional care plan defined data base meal plan for the client discharge instruction The food intake of an individual may be affected by: a. cultural background family income food advertising, fads, prejudices both a and c all of the above In the POMR, the Diagnostic section of the Plan for the client is: a. b. C. used to educate the client about the Dietetic Problem designed to increase the information known about the client overall plan for nutritional care 8. 61 A daily menu consists of: Orange juice (1/2 cup), 2 toast with butter, 1 cup milk, coffee; Ham (2 oz.) sandwich, 1/2 cup fruit cocktail, 2 sugar cookies and coffee, 1 cup milk; Meatloaf (3 02.), l/2 cup mashed potatoes, brown gravy, 1/2 cup green beans, tossed salad with french dressing, 1/2 cup chocolate pudding and tea For an adult woman this daily menu: a. fails to meet the RDA for protein b. fails to meet the RDA for calcium c. includes more than an adequate amount of calories d. is adequate according to the four food groups Match the following Categories of Dietetic Problems with Actual Dietetic Problems: Categories of Dietetic Problems: 1. Nutritional Misconceptions 2. Inadequate Nutritional Intake 3. Economical Food Selection 4. Food Handling and Preparation MethOds 5. Cultural and Religious Implications for Food Selection Actual Dietetic Problems: a. unable to eat due to lack of appetite b. unable to stay within a food budget c. uses vitamin E to slow the aging process d. incorrect preparation of vegetables e. incomplete nutrient consumption due to use of vegetarian diet 10. 11. 12. 13. 62 Sara Smart told the Clinical Dietitian that she (Sara) spends most of her food money on beef, pork, fresh vegetables, ready-to-eat rolls, fresh fruit and readily prepared pies and cakes. There are five (5) members in Sara's family and one refrigerator with a small freezer. Sara usually doesn't have enough food money to last through the whole month. CHOOSE THE DIETETIC PROBLEM: a. Inadequate Dietary Intake b. InapprOpriate Food Preservation c. Inappropriate Use of Food Budget Maria Gonzalez went to the Community Health Center for a physical exam. When talking with the Dietitian, Maria said that the Gonzalez family likes to eat a lot of tamales, tortillas, chili and a variety of beans (pinto, soy and navy). They drink mostly soft drinks and coffee. Marie feels that the family eats well and doesn't need any other types of foods. WHAT BEST DESCRIBES MARIA GONZALEZ'S DIETETIC PROBLEM? Geriatric George believes in using Vitamin E tablets to help him stay young. A diet history done with George reveals that he eats a variety of foods also. Dietetic Problem: Misuse of Vitamin E Which Dietetic Solution would be best to correct Geriatric George's Dietetic Problem? Put an X by the correct answer. a. will take Vitamin E once a week b. will include more fiber in his diet c. will discontinue Vitamin E use d. will take only a B complex tablet Nutritional Information: Martha Ryan has been in an Extended Care Facility (ECF) for a month. During the past month she has expressed dislike of the foods 63 served to her. Martha says that the foods just aren't prepared the way she likes them. Martha's relatives bring her candy and cookies to eat and Martha usually eats all of it. Dietetic Problem: Rejection of Extended Care Facility Meals WRITE YOUR ANSWER FOR THIS QUESTION: What is the best Dietetic Solution for Martha Ryan's Dietetic Problem? 14. Place an X in the blank by the Diagnostic, Therapeutic, and Client Education Statements which are accurately stated: a. Client Education: have client learn about Vegetarian Diets b. Client Education: given a list of foods the client will identify the dairy foods c. Therapeutic: None d. Therapeutic: client will be given ideas for easy to fix foods e. Diagpostic: have client learn quick methods of food preparation 15. Nutritional Information Sara Smart told the Clinical Dietitian that she (Sara) spends most of her food money on beef, pork, fresh vegetables, ready-to-bake rolls, fresh fruit and readily prepared pies and cakes. There are five members in Sara's family and one refrigerator with a small freezer. Sara doesn't have enough food money usually to last through the month. Dietetic Problem: Misconceptions of Economical Food Selection Dietetic Solution: Client will learn methods of economical food selection 64 PUT AN X BY THE CORRECT ANSWER: What is the best Plan of Action for Sara? a. Diagnostic: have social worker assess client's finan— cial status Therepeutic: client will prepare an economical meal Client Education: have client start looking for a larger, second-hand refrigerator b. Diegnostic: None Therapeutic: talk with client about economical food selections Client Education: client will allocate a certain amount of money for the food budget for the month and will report how she uses the money 16. Nutritional Information: Bill Blake is 60 years old and lives alone at home. He has to prepare his own meals which consist mainly of toast, cold cereal, pork and beans, salami sandwiches, t.v. dinners, ice cream and various puddings. His favorite beverages are coffee with cream or hot tea. At times Bill will buy pet food to eat when he doesn't feel like cooking. Bill receives a Social Security Check each month and could afford inexpensive foods that are a good representation of normal nutrition. WRITE YOUR ANSWERS FOR THE FOLLOWING QUESTIONS: What best describes Bill Blake's Dietetic Problem? What is a suitable Dietetic Solution for the Dietetic Problem? 65 What is the best Plan of Action? Diagnostic: Therapeutic: Client Education: 17. 18. PUT AN S BY THE SUBJECTIVE INFORMATION AND 0 BY THE OBJECTIVE INFORMATION: a. Client says that onions give him stomach pain b. Present weight: 135 pounds. Height: 5' 10" as seen in the POMR c. "I hate to eat liver." d. Dietitian observes that little or no food is left on Mary's tray after meals e. Client has lost 8 lbs. in 4 weeks as seen when the Dietitian weighed him f. Client says that he does not add any sugar to his foods Nutritional Information: Mariz Gonzalez went to the Community Health Center for a physi- cal exam. When talking with the Dietitian, Marie said that the Gonzalez family likes to eat a lot of tamales, tortillas, chili and a variety of beans. They drink mostly soft drinks and coffee at meals. Maria feels that the family eats well and doesn't need any other kinds of foods. What best describes Maria's Dietetic Problem? WRITE YOUR ANSWER 66 What Subjective information can you write about Maria Gonzalez? S: What Objective Information can you write about Maria Gonzalez? 0: What Assessment can you write from the Subjective and Objective Information? A: What Plan of Action is now best for Maria Gonzalez? Diagnostic: Therapeutic: Client Education: REVIEW THE ANSWERS FOR THE PRETEST 67 POSTTEST: PROBLEM-ORIENTED MEDICAL RECORD STUDY READ THROUGH THE FOLLOWING NUTRITIONAL INFORMATION CASE STUDIES AND WRITE THE DIETETIC PROBLEMS, INITIAL PLANS AND SOAP PROGRESS NOTES. Nutritional Information: The Dietitian did a Diet History with Genial George. George says that he usually skips Breakfast and eats the following foods during the day: Coffee Breaks: Orange Crush (12 oz.) Coffee: 5-6 cups with sugar Chocolate candy bars Afternoon snack: Cooked White Rice (1 cup) with whole milk (1/2 cup) and sugar Coffee Evening Meal: 1-2 Alcoholic Beverages: Martini or Beer Meat (Veal, Pork or Beef) 6 oz. Potatoes (fried or baked) 1 cup Cooked Vegetable (1/2 cup): carrots, broccoli, asparagus, cauliflower Cake (Angel food, Chocolate, Yellow) 2 glasses Water EVALUATE ALL DIETS ACCORDING TO THE FOUR FOOD GROUPS What best describes George's Dietetic Problem? WRITE YOUR ANSWER AND BE AS SPECIFIC AND CONCISE AS POSSIBLE What would be the best Initial Plan of Action for George? WRITE YOUR ANSWER Diagnostic: Therapeutic: 68 Client Education: New Nutritional Information: Genial George Genial George came back to see the Dietitian and showed her a menu that he wrote for himself to determine if it is adequate according to the Basic Four Food Groups: Menu: Mid-Mornipg Snack: Coffee Grapefruit or Orange Afternoon Snack: Cooked White Rice (1 cup) with whole milk (1/2 cup) and sugar Chocolate Candy Bar Evening Meal: 2 Beers Meat Serving (Veal, Pork or Beef) 6 oz. Vegetable (carrots, broccoli, cauliflower or asparagus) 1/2 cup Cake Dessert WRITE THE DIETETIC PROBLEM AND SOAP PROGRESS NOTE FOR GENIAL GEORGE: Dietetic Problem: Subjective Information: Objective Information: Assessment: Plan: Diagnostic: 69 Therapeutic: Client Education: 70 Nutritional Information: Marsha Mash told the Dietitian that she (Marsha) uses a large quantity of liquid to cook her vegetables in and is sure to cook the vegetables till they are quite tender. Marsha also said that she adds pennies to jars of canned pickles to preserve the green color of the pickles. What best describes Marsha's Dietetic Problem? WRITE YOUR ANSWER. Dietetic Problem: What is the best Initial Plan for Marsha's Dietetic Problem? Diagnostic: Therapeutic: Client Education: 71 New Nutritional Information: Marsha Mash spoke with the Dietitian again about her cooking methods. She said that she now cooks vegetables with less liquid and does not cook the vegetables till they are very tender. Marsha also mentioned that she adds baking soda to her green vegetables to preserve the green color. WRITE THE DIETETIC PROBLEM AND SOAP PROGRESS NOTE FOR MARSHA MASH: Dietetic Problem: Subjective Information: Objective Information: Assessment: Plan: Diagnostic: Therapeutic: Client Education: 72 Nutritional Information: Joe Best recently got laid off from work and now gets an unemployment check each month which is partially used for buying good. His family spends their food money on t.v. dinners, frozen desserts, powdered milk, fresh vegetables and fruits, various bakery breads, ice cream, and puddings. Joe's family has always eaten well and had enough to eat, but the unemployment check now cannot cover food costs. What best describes Joe's Dietetic Problem? WRITE YOUR ANSWER. Dietetic Problem: . What is the best Initial Plan for Joe's Dietetic Problem? Diagnostic: Therapeutic: Client Education: 73 New Nutritional Information: Joe Best told the Dietitian that he made up a food budget plan for two weeks and tried it but still did not have enough money to cover his food costs. Joe said that he would like more help in trying to make his money cover the family's food costs. WRITE THE DIETETIC PROBLEM AND SOAP PROGRESS NOTE FOR JOE BEST: Dietetic Problem: Subjective: Info. Objective: Info. Assessment: Plan: Diagnostic: Therapeutic: Client Education: 142 9222 H u u I" H H R“ H I" N“ I I u 1] 193 03 31 IIHIHWIUH