FROM THE ACADEMY
Question of the Month
Where Can I Find Resources for Medical Record
Documentation?
T
HE HOSPITAL MEDICAL RECORD
constitutes the only permanent
record of a patient’s illness and
treatment. At one time, dieti-
tians routinely kept patient progress
notes in dietary department files.1 In
December of 1965, it was recommended
that the progress notes of the patient’s
medical record was the most appro-
priate place within the medical record
for reporting on dietary consultation,
and guidelines were released in 1966.1
The guidelines were later revised and
included information on how narrative
entries could be structured in the SOAP
(subjective, objective, assessment, plan)
format of medical record documenta-
tion.2 However, the guideline stated,
“Regardless of format used, entries in
the patient’s medical record should
contain sufficient information to sup-
port the dietary assessment, to justify
dietetic care, and to document the re-
sults accurately.”2 Medical record docu-
mentation over the years has included
a variety of strategies in response to
various influences. Ultimately, however,
as noted from the beginning, the docu-
mentation method selected is deter-
mined by the institution where the
dietitian practices.
In 2003, the Academy announced the
adoption of the Nutrition Care Process
and Model in an article describing the
complete Nutrition Care Process (NCP).3
The NCP is intended to provide nutri-
tion and dietetics practitioners with a
framework for critical thinking and
decision-making. The NCP is not inten-
ded to standardize nutrition care for
each patient/client, but to establish a
standardized process for providing in-
dividualized care. Key to identifying
This article was written by Eleese
Cunningham, RDN, of the Academy
of Nutrition and Dietetics’ Knowledge
Center Team, Chicago, IL. Academy
members can contact the Knowledge
Center by sending an e-mail to
knowledge@eatright.org.
http://dx.doi.org/10.1016/j.jand.2015.06.008
1360 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
the unique contributions of registered
dietitian nutritionists (RDNs) is the use
of standardized terminology. Using
standardized terminology in the context
of medical record documentation al-
lows RDNs in all settings to use the
same words to describe things, which
results in more precise and effective
communication. The NCP consists of
four steps: (a) Nutrition Assessment,
(b) Nutrition Diagnosis, (c) Nutrition
Intervention, and (d) Nutrition Moni-
toring and Evaluation. Some RDNs
also use ADIME (A¼Assessment, D¼
Diagnosis, I¼Intervention, M¼Mon-
itoring, E¼Evaluation). Regardless of
format, quality documentation should
include:
 nutrition-related assessment data;
 a clear concise statement of
nutrition diagnosis(es);
 a description of the nutrition
intervention; and
 a description of nutrition moni-
toring and evaluation to identify
patient/client outcomes.4
An update of the NCP focusing
on documentation includes examples
incorporating standardized terminol-
ogy into documentation.4 Additional
case studies, “Inpatient Critical Illness—
Diabetes” and “Outpatient Weight
Management,” are used in examples
showing documentation for the same
case study in a Narrative Format, a
SOAP Format, and ADIME, reiterating
the importance of content over docu-
mentation format. These examples can
be found in the NCP 101 information on
the Academy’s website at: http://www.
eatrightpro.org/resource/practice/nutri
tion-care-process/ncp-101/nutrition-care-
process-the-next-level.
Use of a standardized terminology
enables RDNs to move from documen-
tation in paper medical records to an
integral component of electronic health
records. The profession is currently
transitioning toward RDNs working in a
team environment, providing inter-
ventions, and measuring improved out-
comes via electronic health records.5
ª 2015 by the Academy of Nutrition and Dietetics.
The tools below can assist the RDN in
utilizing the Nutrition Care Process and
helping ensure that critical data are
captured and nutrition care documen-
tation is included in databases and
collected in a consistent way.
References
1. American Dietetic Association. Guidelines
for the therapeutic dietitian in making no-
tations in the medical record. J Am Diet
Assoc. 1966;49(3):215-216.
2. American Dietetic Association. Guidelines
for Recording Nutritional Information in
Medical Records. In: Handbook of Clinical
Dietetics. Chicago, IL: American Dietetic
Association; 1981:113-118.
3. Lacey K, Pritchett E. Nutrition care process
and model: ADA adopts road map to qual-
ity care and outcomes management. J Am
Diet Assoc. 2003;103(8):1061-1072.
4. Writing Group of the Nutrition Care Pro-
cess/Standardized Language Committee.
Nutrition care process part II: Using the
International Dietetics and Nutrition Ter-
minology to document the nutrition care
process. J Am Diet Assoc. 2008;108(8):1287-
1293.
5. Grim J, Roberts S. The Clinical Nutrition
Manager’s Handbook: Solutions for the Busy
Professional. Chicago, IL: Academy of
Nutrition and Dietetics; 2014:192-193.
Additional Resources
Journal of the Academy of Nutrition and Dietetics
Collection: Nutrition Care Process and Termi-
nology. Accessed May 21, 2015. http://www.
andjrnl.org/content/content/nutritioncare.
The Academy of Nutrition and Dietetics Health
Informatics Infrastructure (ANDHII) is an online
tool, available free to Academy members.
Designed to guide dietetics practitioners
through each step of the Nutrition Care Process.
Find out more at: http://www.eatrightpro.org/
resources/practice/nutrition-care-process/andhii.
The NCP Tutorial is a series of 15 videos. Each
module is approximately 10 minutes long. The
modules are free to everyone and available at:
https://ncpt.webauthor.com/encpt-tutorials.
Electronic Nutrition Care Process and Termi-
nology (eNCPT) (formerly IDNT) launched in
2014. The eNCPT is a comprehensive guide for
implementing the Nutrition Care Process using
a standardized language and is available for
purchase at: http://ncpt.webauthor.com.