Chapter 5 Nutrition Care Process

BOX 5.11 Nutrition Monitoring and Evalua- tion Components Summary

Monitor progress: ●

● ●

Check patient/client’s understanding and compliance with nutrition intervention.

Determine whether the intervention is being implemented as prescribed.

Provide evidence that the nutrition interven- tion is or is not changing the patient’s/client’s behavior or status.

● ● Identify other positive or negative outcomes.

Gather information indicating reasons for lack of progress.

● Support conclusions with evidence.

Measure outcomes: ●

●

Select the nutrition care indicator(s) to measure the desired outcome(s).

Use standardized nutrition care indicator(s) to increase the validity and reliability of the measurements of change.

Evaluate outcomes: ●

●

Compare monitoring data with the nutrition prescription/goals or reference standard to assess progress and determine future action.

Evaluate the impact of the sum of all interven- tions on overall patient/client health outcomes.

Source: Academy of Nutrition and Dietetics. Nutrition assessment introduction. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. Nutrition Monitoring and Evaluation Components. http://ncpt. webauthor.com/pubs/idnt-en/page-069. Accessed January 25, 2016.

Nutrition Care Process Documentation Templates

The documentation of nutrition care must be clear, concise, efficient, and understood by others. Docu- mentation that follows the NCP is a communication tool for the RDN and NDTR along with other health care professionals. This documentation method demon- strates the outcomes of nutrition care and can provide research data needed to establish an evidence base regarding the high quality of services provided by RDNs and NDTRs. Figures 5.3 and 5.4 (see pages 67 and 68) are sample templates for documenting initial nutrition assessments and reassessments. These templates are set up in the ADIME (assessment, diagnosis, intervention, and monitoring and evaluation) format to assist readers

in learning the NCP application for medical record documentation.

Academy of Nutrition and Dietetics

Health Informatics Infrastructure The Academy has developed an online tool, the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) that is free to Academy members. It is designed to guide nutrition and dietetics practitioners through documentation of each NCP step and collect data on nutrition care and its impact for use in public policy and quality improvement research. More information about ANDHII is on the Academy’s website (www.eatrightpro.org/resources/practice/nutri- tion-care-process/andhii) (11).

NUTRITION CARE PROCESS

TERMINOLOGY RESOURCES The Nutrition Care Process Terminology (NCPT) is a global system that connects dietetics practitioners through standardized language for international nutri- tion care. The eNCPT (formerly IDNT Online) is a comprehensive online guide for implementing the Nutrition Care Process using a standardized language. The eNCPT is currently utilized in 28 countries and as of 2014 has been translated into 11 different languages for the following countries: Canada (French), Denmark, Switzerland (German), Italy, Japan, Mexico, Norway, South Korea, Sweden, Taiwan (Chinese), and the United Kingdom (British English dialect). The content is reviewed and updated annually by the NCPT Committee with input from the Academy members and 11 other countries. Nutrition and dietetics practitioners may submit requests for additional data to be included in future releases. The terminology is reviewed by the Academy’s NCPT committee, the NCPT Advisory committee, and international representatives. This review process ensures that all countries are repre- sented and their nutritional care needs are met. The Academy website has more information on the submis- sion process (http://ncpt.webauthor.com). Several changes were made to the standardized terminology when eNCPT was released in 2014. The existing terminology for the NCP has been aligned with the Systematized Nomenclature of Medicine (SNOMED), Logical Observation Identifiers Names and Codes (LOINC), and United Medical Language System (UMLS). As such changes are made, they are listed in the “What Is New in This Edition” sections published for each step of the NCP in the eNCPT. Other resources available on the Academy’s

eNCPT website (http://ncpt.webauthor.com) include the Nutrition Assessment Matrix, the Nutrition Diagnosis Etiology Matrix, acknowledgments, a list of

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