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FROM THE ACADEMY

Nutrition Care Process and Model Update:


Toward Realizing People-Centered Care and
Outcomes Management
William I. Swan, FAND; Angela Vivanti, DHSc, AdvAPD*; Nancy A. Hakel-Smith, PhD, RD; Brenda Hotson, MSc, RD‡;
Ylva Orrevall, PhD, RD§; Naomi Trostler, PhD, RD¶, FAND; Kay Beck Howarter, MS, RDN; Constantina Papoutsakis, PhD, RD

T
HE NUTRITION CARE PROCESS The NCPM is updated approximately and Evaluation (Figure 1). The four
(NCP) is a systematic method every 5 years, which aligns with other steps are divided into two compo-
that nutrition and dietetics Academy resources such as Evidence- nents: problem identification and
practitioners use to provide Based Nutrition Practice Guidelines.8 problem solving. This distinction is
nutrition care.1 In this article, nutrition This ensures that the NCPM reflects important for application purposes.
and dietetics practitioners or profes- current practice. Problem identification includes Nutri-
sionals; dietitians; dietitians- This article presents an expert tion Assessment and Reassessment
nutritionists; and dietetic technicians, consensus update review of the NCPM (Step 1), and Nutrition Diagnosis (Step
registered, are collectively referred to completed during the year 2013-2014 2). Problem solving includes Nutrition
as professionals. The Nutrition Care by the Nutrition Care Process and Ter- Intervention (Step 3), and Nutrition
Process Model (NCPM) describes the minology (NCPT) Committee (which Monitoring and Evaluation (Step 4). It
NCP by presenting the workflow of became the Nutrition Care Process has been helpful for new adopters to
professionals in diverse individual and Research Outcomes Committee in implement the NCP in two consecutive
population care delivery settings. 2015) and its international workgroup. phases where Phase 1 involves imple-
Implementation of the NCPM has been Twenty-four experts from around the mentation of problem identification,
associated with several advantages, world participated in a consensus- and Phase 2 involves the addition of
including use of a common framework building process for each component problem solving. Each step is impor-
for nutrition care and research, promo- of the NCPM. They considered com- tant to complete before advancing to
tion of critical thinking, more-focused ments submitted to the NCP website, the next step. In practice, as new in-
nutrition care documentation, increased feedback from translators and users, as formation becomes available, pro-
acknowledgement of the value of well as international information on fessionals revisit previous steps of the
nutrition care by other health care pro- health quality goals. The current NCPM NCP to reassess, update nutrition di-
fessionals, and improved application of update highlights three themes that agnoses, adapt interventions, and/or
evidence-based guidelines.2-5 Potential emerged as a result of the consensus modify goals and monitor outcomes.
target audiences for the NCPM include process: use of concise language in the The NCPM (Figure 2) is depicted uni-
practitioners, educators and students, NCPM, promotion of professionals’ re- directionally where one progresses
professional credentialing agencies, sponsibility for outcomes manage- from Nutrition Assessment and Reas-
health system accrediting agencies, ment, and support for people-centered sessment to Nutrition Diagnosis, and so
health care funding organizations, care (PCC).9 Finally, experts recom- on; yet, in practice, the model is dy-
payers, and clients. mend associated actions to advance the namic and multidirectional to support
The Academy of Nutrition and Di- NCPM as the Academy embarks into its critical thinking and timely care. This is
etetics (Academy) adopted the NCP and second century initiatives toward a important in follow-up care of clients.
NCPM for use in the United States in world where all people thrive through As new information is collected, a
2003.1 Since then, international di- the transformative power of food and professional may revisit previous steps
etetics associations have supported nutrition. International input was an of the process to remove, add, or
adoption of the NCPM.6 The develop- important influence for improvement change nutrition diagnoses, adjust in-
ment history of the NCPM is described of the current revision. The information terventions, or modify goals and
in detail by Hammond and colleagues.7 in this article replaces previous infor- monitoring data. Monitoring and eval-
mation describing the NCPM. uation data from the prior client
*
AdvAPD¼Advanced Accredited Prac- interaction (or visit) is data that begins
tising Dietitian (Australia). ‡Certified in the reassessment of the subsequent
Canada. §Certified in Sweden. ¶Certi- BACKGROUND interaction. Hence, the model carries
fied in Israel.
The NCP is a roadmap and consists of over care from one interaction to the
2212-2672/Copyright ª 2017 by the four separate yet interconnected steps: next.
Academy of Nutrition and Dietetics. Nutrition Assessment and Reassess- The NCPM incorporates scientific
http://dx.doi.org/10.1016/j.jand.2017.07.015
ment, Nutrition Diagnosis, Nutrition evidence and aims to move pro-
Available online 5 October 2017
Intervention, and Nutrition Monitoring fessionals from experience-based to

ª 2017 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2003
FROM THE ACADEMY

Step 1: Nutrition Assessment and Reassessment


Definition and purpose Nutrition Assessment is a systematic approach to collect, classify, and synthesize important and
relevant data from clients (where “client” refers to individual and population). This step also
includes Reassessment, which additionally includes collection of new data, and comparing and re-
evaluating data from the previous interaction to the next. Nutrition Assessment is an ongoing,
dynamic process that involves initial data collection as well as continual reassessment and analysis
of the client’s status compared with accepted standards, recommendations, and/or goals
Data sources/tools for  Screening or referral form
assessment  Client interview
 Medical or health records
 Consultation with other caregivers, including family members
 Community-based surveys and focus groups
 Statistical reports, administrative data, and epidemiologic studies
Types of data collected  Food- and nutrition-related history
 Anthropometric measurements
 Biochemical data, medical tests, and procedures
 Nutrition-focused physical examination findings
 Client history
Nutrition assessment  Review data collected for factors that affect nutrition and health status
components  Cluster individual data to identify at least 1 nutrition diagnosis as described in diagnosis
reference sheets
 Identify accepted standards, recommendations, and/or goals by which data will be compared
Reassessment  Collect new data
components  Compare data with previous interaction/s:
 Compare the monitoring and evaluation outcomes/indicators documented in the previous
interaction to new data
 Evaluate if the client’s nutritional status has changed to demonstrate effectiveness of
intervention
 Evaluate the status of the Nutrition Diagnosis
 Evaluate whether the nutrition assessment data from the previous interaction need to be
reassessed or changed depending on the client’s status or situation
 Identify new nutrition assessment data to monitor and evaluate during the next interaction
Critical thinking  Determining important and relevant data to collect
 Determining the need for additional information
 Selecting assessment tools and procedures that match the situation
 Applying assessment tools in valid and reliable ways
 Validating the data
Determination for If upon completion of an initial Nutrition Assessment or Reassessment, it is determined that the
continuation of care problem cannot be modified by further nutrition care, discharge, or discontinuation from this
episode of nutrition care may be appropriate
Step 2. Nutrition Diagnosis
Definition and purpose Nutrition Diagnosis is a nutrition and dietetics professional’s identification and labeling of an existing
nutrition problem that the nutrition and dietetics professional is responsible for treating
Data sources/tools for Organized assessment data that is clustered for comparison with defining characteristics of
diagnosis suspected diagnoses as listed in diagnosis reference sheets

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Figure 1. The 4 Steps of the Nutrition Care Process Model with distinguishing characteristics.

2004 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
FROM THE ACADEMY

Nutrition Diagnosis The Nutrition Diagnosis is expressed using nutrition diagnostic terms and the etiologies, signs, and
components symptoms that have been identified in the reference sheets describing each diagnosis. There are
three distinct parts to a nutrition diagnostic statement:
1. The Nutrition Diagnosis describes alterations in a client’s status
2. Etiology is a factor gathered during the Nutrition Assessment that contributes to the exis-
tence or the maintenance of pathophysiological, psychosocial, situational, developmental,
cultural, and/or environmental problems
 The etiology is preceded by the words “related to”
 Identifying the etiology will lead to the selection of a nutrition intervention aimed at
resolving the underlying cause of the nutrition problem whenever possible
3. Signs/symptoms (defining characteristics)
The defining characteristics are a cluster of signs and symptoms that provide evidence that a
Nutrition Diagnosis exists
 The signs and symptoms are preceded by the words “as evidenced by”
 Signs are the observations of a trained professional
 Symptoms are changes reported by the client

Nutrition diagnostic A well-written nutrition diagnostic statement should be:


statement  Clear and concise;
 Specific to a client;
 Limited to a single client problem;
 Accurately related to 1 etiology; and
 Based on signs and symptoms from the assessment data

Critical thinking  Finding patterns and relationships among the data and possible causes
 Making inferences
 Stating the problem clearly and singularly
 Ruling in/ruling out specific diagnoses
 Identifying an etiology that may be resolved, lessened, or managed by the Intervention/s
 Identifying signs and symptoms that are measurable or their change may be tracked
 Prioritizing identified problems
Determination for Because the Nutrition Diagnosis names and describes the problem, the determination for problem
continuation of care solving follows the Nutrition Diagnosis step. If a professional does not identify a Nutrition
Diagnosis or the potential exists for a Nutrition Diagnosis to develop, a professional may
determine an appropriate method and interval for continuation of care
Step 3. Nutrition Intervention
Definition and purpose A Nutrition Intervention is a purposefully planned action(s) designed with the intent of changing a
nutrition-related behavior, risk factor, environmental condition, or aspect of health status.
Nutrition Intervention consists of two interrelated components: planning and intervention. The
Nutrition Intervention is typically directed toward resolving the nutrition diagnosis or the nutrition
etiology Less often, it is directed at relieving signs and symptoms
Data sources/tools for  The Academy of Nutrition and Dietetics’ Evidence-Based Nutrition Practice guidelines or other
Interventions evidence-based guidelines from professional organizations
 The Academy of Nutrition and Dietetics’ Evidence Analysis Library and other evidence such as
the Cochrane Library
 Current research literature
 Results of outcome management studies or quality improvement projects

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Figure 1. (continued) The 4 Steps of the Nutrition Care Process Model with distinguishing characteristics.

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2005
FROM THE ACADEMY

Nutrition Intervention 1. Planning


components  Prioritize interventions based on urgency, influence, and available resources
 Write a nutrition prescription based on a client’s individualized recommended dietary
intake of energy and/or selected foods or nutrients based on current reference standards
and dietary guidelines and a client’s health condition and nutrition diagnosis
 Collaborate with the client to identify goals of the intervention for each diagnosis
 Select specific intervention strategies that are focused on the etiology of the problem
and that are known to be effective based on best current knowledge and evidence
 Define time and frequency or care, including intensity, duration, and follow-up
2. Implementation
 Collaborate with the client to carry out the plan of care
 Communicate the plan of nutrition care
 Modify the plan of care as needed
 Follow-up and verify that the plan is being implemented
 Revise strategies based on changes in condition or response to intervention

Critical thinking  Setting goals and prioritizing


 Defining the nutrition prescription or basic plan
 Making interdisciplinary connections
 Matching intervention strategies with client needs, nutrition diagnoses, and values
 Choosing from among alternatives to determine a course of action
 Specifying the time and frequency of care
Determination for If a client has met intervention goals or is not at this time able/ready to make needed changes, the
continuation of care professional may discharge the client from this episode of care as part of the planned intervention
Step 4. Nutrition Monitoring and Evaluation
Definition and purpose During the first interaction, appropriate outcomes/indicators are selected to be monitored and
evaluated at the next interaction. During subsequent interactions, these outcomes/indicators are
used to demonstrate the amount of progress made and whether goals or expected outcomes are
being met. Nutrition monitoring and evaluation identifies outcomes/indicators relevant to the
nutrition diagnosis and intervention plans and goals
Data sources/tools for Self-monitoring data or data from other records including forms, spreadsheets, and computer
Nutrition Monitoring programs
and Evaluation Anthropometric measurements, biochemical data, medical tests, and procedures
Client surveys, pretests, posttests, and/or questionnaires
Mail, telephone, and electronic media follow-up, such as e-mail
Types of outcomes  Nutrition-related history
measured  Anthropometric measurements
 Biochemical data, medical tests, and procedures
 Nutrition-focused physical findings
 Knowledge gained
 Behavior change
Nutrition Monitoring  In the first interaction: Select appropriate outcomes/indicators
and Evaluation  In subsequent interactions
components
This step includes three distinct and interrelated processes
1. Monitor progress
 Check client understanding and adherence with plan;
 Determine whether the intervention is being implemented as prescribed;

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Figure 1. (continued) The 4 Steps of the Nutrition Care Process Model with distinguishing characteristics.

2006 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
FROM THE ACADEMY

 Provide evidence that the plan/intervention strategy is or is not changing client behavior
or status;
 Identify other positive or negative outcomes;
 Gather information indicating reasons for lack of progress; and
 Support conclusions with evidence
2. Measure outcomes/indicators
 Gather data for outcomes/indicators that are relevant to the nutrition diagnosis or signs
or symptoms, nutrition goals, medical diagnosis, outcomes, and quality management
goals
3. Evaluate outcomes/indicators
 Compare current findings with previous status, intervention goals, and reference
standards
Critical thinking Selecting appropriate outcomes/indicators
 Using appropriate reference standard for comparison
 Defining where client is in terms of expected outcomes
 Explaining variance from expected outcomes
 Determining factors that help or hinder progress
 Deciding between discharge or continued care

Determination for Based on the findings, the professional may actively continue care; or if nutrition care is complete or
continuation of care no further change is expected, discharge the client. If nutrition care continues, reassessment may
result in refinements to the diagnosis and intervention. If care does not continue, a client may still
be monitored for a change in status and re-enter nutrition care at a later date
Figure 1. (continued) The 4 Steps of the Nutrition Care Process Model with distinguishing characteristics.

evidence-based practice. The NCPM family and caregivers) and structures causes. Nutrition Assessment is initi-
strives to provide quality, consistent (eg, social service agencies and faith- ated from nutrition screening or client
practice and to achieve expected out- based organizations). In the Core, the referral. Nutrition Assessment is a
comes at all levels of career develop- word interacts describes the dynamic continuous process requiring initial
ment. If the NCPM is applied relationship between a professional data collection with continued reas-
consistently, quality of care and and a client in which PCC and client sessment and analysis of a client’s data
improved health outcomes should engagement contribute to treatment compared with accepted standards,
enhance recognition for professionals decisions, intervention strategies,10 or recommendations, and/or goals like
on multidisciplinary teams. Current environment changes. Interacts is a growth charts, dietary guidelines, and/
research demonstrates that it is broader and more inclusive word than or individual needs. Although pro-
possible to measure application of the relationship, which was used in the fessionals are familiar with performing
NCPM and demonstrate efficacy of the previous NCPM.11 Interacting encom- a Nutrition Assessment, the systematic
NCPM in practice.5 passes the care of populations and approach of Nutrition Assessment and
groups as well as individuals. For Reassessment coupled with standard-
NCPM example, a population survey is an ized terminology facilitates organized
interaction not a relationship. An documentation, encourages critical
Core interview is an interaction between a thinking, and supports communication,
The focus of the NCPM is a central Core client and a professional through collaboration, and quality care for cli-
that embraces the many and varied which a relationship can develop. Also, ents with nutrition-related problems.4
areas in which nutrition and dietetic an in-person or remote visit with cli- In this update, Nutrition Assessment
care is practiced. Consequently, pro- ent(s) is an interaction. and Reassessment is clarified further to
fessional interactions that influence describe specifically what a profes-
individuals and populations are recog- sional is expected to do (Figure 3). A
nized and incorporated into the model. Nutrition Assessment and critically thoughtful professional ac-
Populations refers to demographically Reassessment: Step 1 quires, analyzes, and interprets the
defined groups or otherwise identifi- Nutrition Assessment and Reassess- important and relevant data contrib-
able groups. Individuals and pop- ment is a systematic approach for col- uting to the potential nutrition-related
ulations are referred to as clients lecting, classifying, and synthesizing problem or problems. Critical thinking
throughout this article and client also data to describe nutritional status, tasks may vary with level of practice
includes supportive individuals (eg, related nutrition problems, and their (Figure 4).12

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2007
FROM THE ACADEMY

Figure 2. The Nutrition Care Process (NCP) Model.

The data collected and analyzed data of the previous interaction(s) information to develop or modify a
during this step direct professionals in inform Reassessment and the possibil- Nutrition Diagnosis that best fits the
the selection of a Nutrition Diagnosis. ity for changed nutrition diagnoses. present situation of a client.
New information that is collected dur- Thus, in a follow-up interaction, the
ing follow-up interactions (ie, in- Reassessment begins where Moni-
teractions that occur after the initial toring and Evaluation ended during the Nutrition Diagnosis: Step 2
one), and comparison of data between previous interaction. It should be From Nutrition Assessment data, a
interactions provide the basis for highlighted that Reassessment is not professional is able to determine
Reassessment, and the possibility for only comparing results from one whether there is a nutrition problem
changed or resolved Nutrition Di- interaction to the next to establish and label it as a Nutrition Diagnosis.
agnoses. As the nutrition intervention change/progress between interactions. Nutrition Diagnosis identifies and de-
unfolds during follow-up interactions, Reassessment is also an opportunity to scribes a specific problem or problems
the relevant Monitoring and Evaluation collect new important and relevant that can be resolved or improved

2008 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
FROM THE ACADEMY

through Nutrition Intervention. A nutrition problem and the client’s whether Reassessment is necessary.
Nutrition Diagnosis (eg, inconsistent values and safety (Figure 4). Nutrition Standardized terms to assess the extent
carbohydrate intake)13 is different from intervention has two related planning of Nutrition Diagnosis resolution have
a medical diagnosis (eg, diabetes mel- phases. In the first phase, the profes- not been developed. But, as an
litus). As the client responds to Nutri- sional and client jointly determine example, the Academy of Nutrition and
tion Intervention, the Nutrition achievable and measurable goals. Dietetics Health Informatics Infra-
Diagnosis can improve or resolve. These goals are important to define the structure (ANDHII) currently uses the
Critical thinking is needed to prioritize time frame during which the nutrition following descriptors for resolution:
nutrition diagnoses for Nutrition problem is to be resolved, provide di- resolved, continued, and removed (for
Intervention. As shown in Figure 4, a rection to the plan, select and imple- more information on ANDHII, see the
variety of critical thinking tasks are ment interventions intended to achieve dedicated section in this article). A
important to develop the Nutrition the goals, provide criteria to measure Nutrition Diagnosis can be monitored
Diagnosis. For example, stating the results of intervention during Nutrition and evaluated at the end of a single
problem clearly and singularly is ex- Monitoring and Evaluation, and eval- visit. For example, learning assessment
pected to be carried out efficiently by a uate effectiveness of intervention and may be evaluated at the conclusion of a
novice professional. Other skills, such revise when indicated. The next phase nutrition education session.
as finding patterns, may be conquered is to determine the nutrition prescrip-
with greater experience. It is possible tion and interventions that will meet
and desirable that professionals of all the agreed upon goals. The specified Framing Rings
career stages are able to carry out activity to determine a nutrition pre- Two framing rings (outer and middle)
necessary critical thinking tasks.14 scription, a client’s recommended di- contextualize the four steps of the NCP
The Nutrition Diagnosis is commu- etary intake based on current reference (inner ring), and the Core (Figure 2).
nicated as an identify problem, deter- standards and dietary guidelines,13 is The outer ring represents the social
mine etiology/cause, and state signs new to the current revision of NCPM context of nutrition care. There are no
and symptoms (PES) statement. This (Figure 3). changes in the terms used to define the
PES statement is written with linking Interventions are a planned set of outer ring. However, the scope of these
words (ie, problem “related to” etiology specific behaviors or actions per- terms is broader. As defined in 2008,
“as evidenced by” signs and symp- formed, delegated, coordinated, or the outer ring represented the in-
toms). The NCPT, which is discussed recommended by a professional that fluences on how people received
more later in this article, provides a move a client toward a desired nutrition information.11 In the updated
standardized nutrition diagnostic ter- outcome. The chosen interventions NCPM, this ring also represents how
minology that defines nutrition prob- intend to alter or eliminate the etiology professionals engage their clients. Ex-
lems.13 It is important to review the to resolve the Nutrition Diagnosis. amples of client engagement in the
specific Nutrition Diagnosis definition With goals agreed upon, prescription outer ring include advocating public
to confirm that this is the most and interventions selected, action is policy within social systems or using a
appropriate Nutrition Diagnosis for the undertaken to implement Nutrition client portal within a health care sys-
situation. It is as important to review Intervention before proceeding to tem’s electronic health record for
the reference sheet of the Nutrition Monitoring and Evaluation. chronic care management.
Diagnosis from the NCPT to verify that The middle ring represents the
at least one indicator described in the required qualities and attributes that
respective reference sheet is present in Nutrition Monitoring and differentiate the nutrition and dietetics
the client’s assessment data. Next, a Evaluation: Step 4 professionals from other professions.11
professional determines the etiology or During Nutrition Monitoring and Eval- This is to emphasize that the nutrition
root cause of the nutrition problem. uation, a professional examines the and dietetics professionals contribute
The selection of interventions that timely results following implementa- the critical thinking, code of ethics, and
address the etiology are more likely to tion of Nutrition Interventions. For this evidence-based practice that are
provide desired nutrition care out- update, wording was clarified to unique to nutrition and dietetics sci-
comes. To finalize the PES statement, a incorporate key Nutrition Monitoring ence and practice. A significant change
professional selects signs and symp- and Evaluation practice actions within the middle ring was placing the
toms that can demonstrate resolution (Figures 2 and 3). These actions include word documentation in this ring after
or improvement in the nutritional selecting quality indicators derived removing the word document from
diagnosis as a result of Nutrition from best practices and evidence-based each step of the NCP. The expectation
Interventions. guidelines. Indicators use readily to document the NCP remains.
available data to provide a quantitative Although one may argue that commu-
measure for health professionals, or- nication, also included in this ring, im-
Nutrition Intervention: Step 3 ganizations, and planners aiming to plies the act of documentation, in some
When possible, Nutrition Intervention achieve improvement in the care and countries communication might be
is collaborative between a professional the processes by which client care is limited to verbal means and docu-
and a client. The professional plans the delivered.15 mentation may not be required or
Nutrition Intervention after prioritizing A professional monitors and evalu- might not be an allowed privilege for
Nutrition Diagnoses by critically ates the progress or resolution of the nutrition and dietetics professionals.
considering the severity of the Nutrition Diagnosis and determines The explicit inclusion of the concept of

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2009
FROM THE ACADEMY

Function The NCP Model The NCP Model


Review year 2008 2015
Standardized language  International Dietetics and Nutrition  Electronic
Terminology  NCP Terminology
 Print format (book)  Electronic format (web-based)
 Second edition (purple cover)
 Third edition (green cover)
 Fourth edition (yellow cover)
Nutrition Assessment and  Obtain/collect timely and appropriate data  Obtain/collect important and
Reassessment step  Analyze/interpret with evidence-based relevant data
(inner ring) standards  Analyze/interpret collected data
 Document
Nutrition Diagnosis step  Identify and label problem  Identify problem
(inner ring)  Determine cause/contributing risk factors  Determine etiology/cause
 Cluster signs and symptoms/defining  State signs and symptoms
characteristics
 Document
Nutrition Intervention  Plan nutrition intervention (set goals and  Determine intervention and
step (inner ring) determine a plan of action) prescription
 Implement nutrition intervention (care is  Formulate goals and determine
delivered and actions are carried out) action
 Document  Implement action
Nutrition Monitoring  Monitor progress  Select or identify quality indicators
and Evaluation step  Measure outcome indicators  Monitor and evaluate resolution of
(inner ring)  Evaluate outcomes diagnosis
 Document
Outcomes management  Monitor the success of the NCP  Research NCP
system implementation  Use aggregated data to conduct
 Evaluate influence with aggregate data research
 Identify and evaluate causes of less-than-  Conduct continuous quality
optimal performance and outcomes improvement
 Refine use of NCP  Calculate and report quality
indicators
Center circle (core)  Relationship between patient/client/group  Individual/population interacts with
and nutrition and dietetics practitioner nutrition and dietetics practitioner
Middle ring  Dietetics knowledge  Dietetics knowledge
 Skills and competencies  Skills and competencies
 Critical thinking  Critical thinking
 Collaboration  Collaboration
 Communication  Communication
 Evidence-based practice  Evidence-based practice
 Code of ethics  Code of ethics
 Documentation
Outer ring  Practice settings  Practice settings
 Health care systems  Health care systems
 Social systems  Social systems
 Economics  Economics

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Figure 3. Comparison of functions in the Nutrition Care Process (NCP) Model.

2010 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
FROM THE ACADEMY

Function The NCP Model The NCP Model


Screening and referral  Identify risk factors  Identify risk factors
system  Use appropriate tools and methods  Use appropriate tools and methods
 Improve interdisciplinary collaboration  Improve interdisciplinary
collaboration
Figure 3. (continued) Comparison of functions in the Nutrition Care Process (NCP) Model.

documentation in a framing ring was parts of the NCPM and its supporting already have or are at risk for nutrition-
deemed appropriate and necessary to structures and did not need designation related problems, who are appropriate
underline that documentation is a within the NCPM. Informatics tools may for nutrition care services, and who
requirement for professionals adopting not be available to all professionals and would benefit from participation in the
the NCPT internationally. This was professionals depend upon the outer NCP. The nutrition screening process
important given the range of practices ring for their availability. applies appropriate, valid, and reliable
or requirements internationally that screening tools and resources to iden-
vary from documentation in the health tify and recognize nutritional risk
record which is a legal requirement in SUPPORTING STRUCTURES factors.
some countries to no written docu-
mentation by dietitians because of Screening and Referral System
different levels of privileges. Docu- The Screening and Referral System is Outcomes Management System
mentation is a desirable source of data external to the rings of the NCP The Outcomes Management System is
for monitoring and evaluating care and because it may be carried out by col- a supporting structure outside the NCP
supporting the Outcomes Management laborators outside the nutrition and because it can be operated by members
System. dietetics profession. This supporting of various professions. As with Nutri-
The role and placement of nutrition system is often developed and tion Screening and Referral, the Out-
informatics in the framing rings was managed by professionals. The purpose comes Management System intends to
considered. The consensus was that of this system is to identify and refer be collaborative with leadership from
informatics provides useful tools for all those individuals and populations who professionals. In 2008, the Outcomes

Assessment& Re-assessmentb
Novicea Determining important and relevant data to collect – Ca
N Rule and tool dependent Determining the need for additional information – Ca
Lacks context and discretionary judgement Selecting assessment tools and procedures that match the
situation – Ca
Beginnera
B Starts to appreciate context Diagnosisb
Controlled learning Finding patterns and relationships among the data and
Treats aspects of work equally possible causes - Pa
Stating the problem clearly and singularly - Na
Competenta Nutrition Identifying an Etiology that may be resolved, lessened or
C Encounters novel care managed by the Intervention/s - Ca
Begins to ID important vs unimportant data Identifying signs and symptoms that are measurable or their
Selects rules and tools appropriate to task Care change may be tracked - Ba
Prioritizing identified problems - Pa
Proficienta
P Organized thought patterns Process
Interventionb
Setting goals and prioritizing - Pa
Innovation, Prioritization Defining the nutrition prescription or basic plan - Na
Situational discrimination Making interdisciplinary connections - Pa
Problem solving based on experience Matching intervention strategies with client needs, nutrition
diagnoses, and values - Ca
Advanced Practice/Experta Choosing from among alternatives to determine a course of
A Monitors performance action - Ca
Does not rely on rules and principles
Intuitive; Sees whole situation Monitoring & Evaluationb
Selecting appropriate outcomes/indicators - Aa
Using appropriate reference standard for comparison - Na
Explaining variance from expected outcomes – Aa
Deciding between discharge or continued care - Ca

Figure 4. Acquisition of Nutrition Care Process (NCP) critical thinking. aAdapted with permission from: Charney P, Peterson SJ.
Critical thinking skills in nutrition assessment and diagnosis. http://www.eatrightpro.org/resource/practice/position-and-practice-
papers/practice-papers/practice-paper-critical-thinking-skills-in-nutrition-assessment. Published November 2013. Accessed
February 16, 2017.12. bFor each NCP step, the stated critical thinking task is labeled with the career development stage by which
one should feel confident performing the task. ID¼identification.

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2011
FROM THE ACADEMY

Management System emphasized reporting of quality indicators pursued collection of terms focused on public
improving and strengthening the by other national health systems. These health, and alternative synonyms
NCPM within the profession through activities support professionals’ ability for some behavior-related terms
the following four actions: monitor the to report quality measures and other considered harsh by the international
success of the NCP implementation, results from the Outcomes Manage- community. Documentation of the NCP
evaluate the influence [of the NCP] ment System to the framing rings. The using the NCPT creates data. The need
with aggregate data, identify and Outcomes Management System is to systematically collect these data and
analyze causes of less than optimal linked to the selection of quality in- research the NCP led to the design of
[NCP] performance and outcomes, and dicators during Nutrition Monitoring ANDHII, a web-based data registry.
refine the use of the NCP. These out- and Evaluation. Through the fully
comes management actions continue deployed Outcomes Management Sys-
and are combined in the updated tem, professionals influence the NCP ANDHII
model as Research NCP (Figure 2 and environment defined by the framing ANDHII is a data aggregation platform
Figure 3). rings. designed to collect data generated by
The updated NCPM challenges pro- the application of the NCP. The plat-
fessionals to demonstrate the form has three functions: Smart Visits
improved nutritional health of clients NCPT that enable data entry; Dietetics Out-
through participation in research and A terminology that describes the NCP is comes Registry that generates reports
quality improvement activities. Aggre- necessary to document the delivery using the aggregated data and support
gated data continue to be the founda- and study of nutrition care. Creation of comparative effectiveness studies; and
tion of NCP research. Infrastructure to the NCPT is a contemporaneous Nutrition Research Informatics, which
aggregate and manage data from the endeavor with the development of the facilitates data collection and manage-
NCP did not exist in 2008. An example NCP. Terminology work began in ment for quality improvement and
of this new infrastructure is the AND- 2003,18 and a terminology to support research projects. The structure of
HII.16 ANDHII makes possible the new the NCP was published as a printed ANDHII is the NCP with data being
activity, “Use aggregated data to manual in 2009: International Dietetics derived from NCPT.
conduct research.” This wording places and Nutrition Terminology Reference Data aggregation schemes abound in
Outcomes Management in the center of Manual: Standard Language for the health care. Data are routinely sub-
research priorities, which is necessary Nutrition Care Process.19 In 2014, Inter- mitted to health information ex-
to drive improvements at the organi- national Dietetics and Nutrition Ter- changes, accreditation agencies, payers,
zation and health systems levels.17 The minology was converted to an and government departments and
implication is that all professionals electronic database, called the eNCPT, ministries. Examples include metrics
when using the NCP become research as the management of an expanding required by The Joint Commission
participants as data contributors. Out- terminology (Figure 3) exceeded the concerning patient safety or informa-
comes Management is no longer a capabilities of a printed manual. eNCPT tion about 30-day readmissions
function reserved for those knowl- is currently translated from US English requested by the Centers for Medicare
edgeable in research design, data pro- into Swedish, German (Swiss), French and Medicaid Services.
cessing, and statistical analysis; rather, (Canadian), Norwegian, and Danish. At As with any electronic platform, the
it becomes an integral, collaborative the time of this writing, Chinese Academy continuously works to
activity for all professionals. (Simplified), Chinese (Mandarin), Por- improve ANDHII’s usability and func-
Outcomes research not only includes tuguese (Brazilian), and Spanish tionality to meet technologic, legisla-
NCP research to benefit professional (Mexican) translations are in progress. tive, and international needs. There is
development and practice, but also NCPT can be used to document potential for international use of AND-
aims to show the beneficial effect of nutrition care in any medium, but it is HII, although associated costs, trans-
the NCP on the health of clients.5 To fundamental when documenting in an lation, and varying research ethics
this end, two new activities are incor- electronic health record. In 2011, work regulations will need to be addressed.
porated into the Outcomes Manage- began to map and model the NCPT into ANDHII has been used to explore the
ment System of this updated NCPM. international medical terminology feasibility of validating malnutrition
First, “Conduct continuous quality standards. Mapping and modeling are diagnostic criteria by aggregating data
improvement” applies to improving essential for NCPT to be included in the from the United States and Australia.20
the model and care delivery as pro- document architecture for certified US ANDHII has also been used to investi-
fessionals participate in a learning or- electronic health records. These termi- gate the influence of evidence-based
ganization. The second activity, nologies have also been adopted in nutrition practice guidelines for the
“Calculate and report quality in- other countries. Mapping and prevention of diabetes on both practice
dicators,” supports the Academy’s modeling are continuous processes patterns and patient outcomes.5,21,22
engagement to promote the reporting because new terms are regularly being These studies have demonstrated the
of malnutrition quality measures added to the NCPT. Recent additions potential of incorporating tools such as
within the US health care system, include terms describing findings of ANDHII into practice. With the avail-
(http://www.eatrightpro.org/resource/ the Nutrition Focused Physical Exami- ability of ANDHII, the Outcomes Man-
practice/quality-management/quality- nation, terms resulting from moving agement System can be integrated into
improvement/malnutrition-quality- Malnutrition Disorders into the clinical practice much like the process of
improvement-initiative), and the domain of Nutrition Diagnosis, a learning to write a Nutrition Diagnosis.

2012 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
FROM THE ACADEMY

LOOKING AHEAD  support the NCP in diverse following implementation across a state-
wide health-care system. Nutr Diet.
This article describes the current NCPM practice cultures;
2015;72(3):222-231.
update and compares and contrasts it  determine economic value of
5. Thompson KL, Davidson P, Swan WI, et al.
with the 2008 version of the model.11 dietitian/nutritionist inter- Nutrition care process chains: The
Themes that emerged were concise ventions with clients; and “missing link” between research and
language to promote translation,  continue international evidence-based practice. J Acad Nutr Diet.
2015;115(9):1491-1498.
dissemination and adoption of NCP, collaborations.
6. International Confederation of Dietetic
promotion of professional-driven out- Associations. “Dietetics around the
comes management with the emer- World: The Newsletter of the ICDA.”
Continuous Training Focused on 2011;18(2):2.
gence of smartphone applications and Practice Area and Professional’s 7. Hammond MI, Myers EF, Trostler N.
web-based data aggregation tools, and Career Development Stage Nutrition Care Process and Model: An
embracing PCC.9 Further, the article academic and practice odyssey. J Acad
describes how the NCPM is supported  Adopt NCPM to all stages of Nutr Diet. 2014;114(12):1879-1894.
by its standardized terminology, NCPT, career development, novice 8. Papoutsakis C, Moloney L, Sinley RC,
and outlines ongoing integration of through expert; Acosta A, Handu D, Steiber AL. Academy
of Nutrition and Dietetics methodology
NCPM/NCPT into an innovative out-  use NCPM as a framework for all for developing evidence-based nutrition
comes management platform.16 practice areas, including public practice guidelines. J Acad Nutr Diet.
The NCP and NCPM will continue to health, health promotion, and 2016;117(5):794-804.
undergo evaluation and updating. The disease prevention; 9. World Health Organization. People Cen-
 study NCPM as an effective tool tred Care in Low- and Middle-Income
supporting NCPT will require refine- Countries—Meeting Report. Geneva,
ment to sustain the reporting of quality for educating professionals in Switzerland: World Health Organization;
measures and outcomes. Over the 14 science-based practice; and 2010.
years of the NCPM’s adoption, the NCP  train professionals to effectively 10. Sladdin I, Ball L, Bull C, Chaboyer W. Pa-
community has been growing and and efficiently use PCC resources tient-centred care to improve dietetic
practice: An integrative review. J Hum
actively contributes to the global up- and techniques. Nutr Diet. 2017;30(4):453-470.
take, improvement, and research of the 11. Nutrition Care Process and Model part I:
NCP.4-6,23-30 The NCPM has evolved What Professionals Can Do The 2008 update. J Am Diet Assoc.
with practice from a professional- 2008;108(7):1113-1117.
defined care delivery system to a PCC  Participate in the future and 12. Charney P, Peterson SJ. Practice Paper of
the Academy of Nutrition and Dietetics:
interaction. The NCPM progresses from share your plans at ncp@
Critical thinking skills in nutrition
learning to write nutrition diagnoses to eatright.org. assessment and diagnosis. J Acad Nutr
routinely entering outcomes of care  Contribute data to ANDHII to Diet. 2013;113(11):1545.
using a data aggregation tool. The NCP support outcomes research. 13. Academy of Nutrition and Dietetics.
is evolving to become the international  Collaborate in a translation of Nutrition Terminology Reference Manual
(eNCPT): Dietetics Language for Nutrition
standard for nutrition and dietetics NCP and NCPT. Care. Chicago, IL: Academy of Nutrition
care delivery. To foster this maturation,  Pursue continuing education and Dietetics; 2016.
three areas of focus are recommended: focused on quality indicators. 14. Shiner R, Tanner E, Collins C. RDN practice
 Advocate for the value that the level and application of the Nutrition Care
Creation of New Knowledge Process. J Acad Nutr Diet. 2015;115(9):A25.
NCP brings to the health of
clients. 15. Mainz J. Defining and classifying clinical
 Support NCP-related research; indicators for quality improvement. Int J
 Apply the NCP to create oppor-
 use aggregated data to study all Qual Health Care. 2003;15(6):523-530.
steps of the NCP in a variety of tunities that integrate research,
16. Murphy WJ, Steiber AL. A new breed of
populations, practice cultures, professional development, and evidence and the tools to generate it:
and stages of professionals’ practice for innovation and Introducing ANDHII. J Acad Nutr Diet.
discovery. 2015;115(1):19-22.
career development; 17. Porter ME, Larsson S, Lee TH. Standard-
 validate expected plans of care izing patient outcomes measurement.
that link nutrition diagnoses References N Engl J Med. 2016;374(6):504-506.
1. Lacey K, Pritchett E. Nutrition Care Pro-
with specific interventions to cess and Model: ADA adopts road map to 18. Nutrition Care Process part II: Using the
demonstrate effectiveness; quality care and outcomes management. International Dietetics and Nutrition Ter-
 J Am Diet Assoc. 2003;103(8):1061-1072. minology to document the Nutrition Care
investigate whether the NCP
Process. J Am Diet Assoc. 2008;108(8):
improves outcomes compared 2. Hakel-Smith N, Lewis NM. A standardized 1291-1293.
nutrition care process and language are
with not using the NCP; 19. International Dietetics and Nutrition Ter-
essential components of a conceptual
 define appropriate nutrition and model to guide and document nutrition minology (IDNT) Manual. Chicago, IL:
dietetics outcomes; and care and patient outcomes. J Am Diet American Dietetic Association; 2012.
 enhance and develop electronic, Assoc. 2004;104(12):1878-1884. 20. Hand RK, Murphy WJ, Field LB, et al.
digital standards, and structures 3. Memmer D. Implementation and practical Validation of the Academy/A.S.P.E.N.
application of the Nutrition Care Process malnutrition clinical characteristics.
that accept NCP data. in the dialysis unit. J Ren Nutr. 2013;23(1): J Acad Nutr Diet. 2016;116(5):856-864.
65-73. 21. Hand RK, Abram JK. Sense of competence
Globalization of the NCP 4. Vivanti A, Ferguson M, Porter J, impedes uptake of new Academy
O’Sullivan T, Hulcombe J. Increased fa- Evidence-Based Practice Guidelines: Re-
 Promote adoption of the NCP miliarity, knowledge and confidence with sults of a survey. J Acad Nutr Diet.
and translations of the NCPT; Nutrition Care Process Terminology 2016;116(4):695-705.

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2013
FROM THE ACADEMY

22. Murphy WJ, Yadrick MM, Hand RK. Vali- 25. Porter JM, Devine A, O’Sullivan TA. hemodialysis unit: Comparing paper vs
dation of an Automated Process for the Evaluation of a Nutrition Care Process electronic records. J Acad Nutr Diet.
Comparison of Nutrition Care with implementation package in hospital di- 2014;114(1):124-130.
Evidence-Based Nutrition Practice Guide- etetic departments. Nutrition & Dietetics. 28. Porter JM, Devine A, Vivanti A, Ferguson M,
lines. Chicago, IL: American Medical 2015;72(3):213-221. O’Sullivan TA. Development of a Nutrition
Informatics Association; 2016. Care Process implementation package for
26. Lovestam E, Orrevall Y, Koochek A,
23. Hakel-Smith NA, Lewis NM, Eskridge KM. Karlstrom B, Andersson A. Evaluation of a hospital dietetic departments. Nutr Diet.
A methodology for evaluating documen- Nutrition Care Process-based audit instru- 2015;72(3):205-212.
tation of the Nutrition Care Process. J Am ment, the Diet-NCP-Audit, for documen- 29. Murphy WJ, Hand RK, Steiber AL. Practi-
Diet Assoc. 2007;107(8):A79. tation of dietetic care in medical records. calities of using the Nutrition Care Process
Scand J Caring Sci. 2014;28(2):390-397. in research. J Ren Nutr. 2015;25(4):393-394.
24. Atkins M, Basualdo-Hammond C, Hotson B.
Canadian perspectives on the nutrition 27. Rossi M, Campbell KL, Ferguson M. 30. Steiber AL, Leon JB, Hand RK, et al. Using a
care process and international dietetics Implementation of the Nutrition Care web-based nutrition algorithm in hemo-
and nutrition terminology. Can J Diet Pract Process and International Dietetics and dialysis patients. J Ren Nutr. 2015;25(1):
Res. 2010;71(2):e18-e20. Nutrition Terminology in a single-center 6-16.

AUTHOR INFORMATION
W. I. Swan is chair, Nutrition Care Process Outcomes Committee of the Academy of Nutrition and Dietetics, Taos, NM. A. Vivanti is chair, Nutrition
Care Process Outcomes International Workgroup of the Academy of Nutrition and Dietetics; a research and development dietitian, Department
of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Australia; and a senior lecturer, School of Human Movement and Nutrition
Studies, University of Queensland, Queensland, Australia. N. A. Hakel-Smith is a member of the Nutrition Care Process Outcomes Advisory
Workgroup of the Academy of Nutrition and Dietetics, and a manager, Clinical Nutrition Services, Bryan Medical Center, Lincoln, NE. B. Hotson is a
member of the Nutrition Care Process Outcomes Committee of the Academy of Nutrition and Dietetics; a member of the Nutrition Care Process
Outcomes International Workgroup of the Academy of Nutrition and Dietetics; and a regional clinical manager-acute care, Nutrition & Food
Services, Winnipeg Regional Health Authority, Winnepeg, Manitoba, Canada. Y. Orrevall is a member of the Nutrition Care Process Outcomes
International Workgroup of the Academy of Nutrition and Dietetics; head of research and development, Education & Innovation, Function Area
Clinical Nutrition, Karolinska University Hospital, Stockholm, Sweden; and is in the Department of Learning, Informatics, Management, and Ethics,
Karolinska Instutet, Stockholm, Sweden. N. Trostler is a member of the Nutrition Care Process Outcomes Committee of the Academy of Nutrition
and Dietetics; a member of the Nutrition Care Process Outcomes International Workgroup of the Academy of Nutrition and Dietetics; and a
retired professor, Faculty of Agriculture, Food, and Environmental Sciences, Hebrew University of Jerusalem, Rehovot, Israel. K. Beck Howarter is
principal, Ms. Nutrient Food and Nutrition Consulting Services, Evanston, IL; at the time of the study, she was director, Nutrition Care Process,
Research International Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL. C. Papoutsakis is director, Nutrition Care Process,
Research International Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL; at the time of the study, she was member of the
Nutrition Care Process Outcomes International Workgroup of the Academy of Nutrition and Dietetics, Chicago, IL.
Address correspondence to: Constantina Papoutsakis, PhD, RD, Academy of Nutrition and Dietetics, 120 S Riverside Plaza, Suite 2190, Chicago,
IL 60606. E-mail: cpapoutsakis@eatright.org
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
The Academy is the source of funding for the present Nutrition Care Process Model update. The authors and experts who conducted the
Nutrition Care Process Model update had complete autonomy during all stages of the update and writing of the present manuscript.
ACKNOWLEDGEMENTS
The authors thank those additional members of the Nutrition Care Process and Terminology Committee Research (NCP/T) Committee and the
NCP/T International Workgroup who served during 2013-2014 (Terry Brown, MBA, MPH, RD, LD, CNSC; Joyce Buhler, RDN, CDE, CD; Elizabeth
Copes, RDN, LD, CNSC; Ingrid Darnley, Maree Ferguson, PhD, MBA, AdvAPD, RD; Margaret Garner, MS, RD, LD; Debra Geary Hook, MPH, RD, CNSD,
CHES; Sue Kellie, MSc, FBDA; Yen Peng Lim, MHSc (Aust), PhD, ADS (Accredited Dietitian Singapore); Elisabet Rothenberg, PhD, RD; Carolyn Silzle,
MBA, MS, RD, LD; Christina Sollenberg, MSc, RD; Lyn Lloyd, RD; Maggie Gilligan, RD, CSG; Paula-Ritter-Gooder, PhD, RD, CSG, LMNT; Camela Rising,
MS, RDN, LDN; Lorraine Witherspoon, PhD, RD; and Jennifer A. Wooley, MS, RD, CNSC); and Academy of Nutrition and Dietetics staff members
Alison Steiber, PhD, RDN (chief science officer), Katie Gustafson (research assistant), and Robert Voss (NCP manager).

2014 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
FROM THE ACADEMY

Nutrition Care Process (NCP) Update Part 2:


Developing and Using the NCP Terminology
to Demonstrate Efficacy of Nutrition Care
and Related Outcomes
William I. Swan, FAND; Donna G. Pertel, MEd, RD, LDN; Brenda Hotson, MSc, RD*; Lyn Lloyd, RD‡; Ylva Orrevall, PhD, RD§;
Naomi Trostler, PhD, RD, FADN; Angela Vivanti, DHSc, AdvAPD¶; Kay Beck Howarter, MS, RDN; Constantina Papoutsakis, PhD, RD

N
UTRITION AND DIETETICS illustrate how the NCPT communicates To address this gap in nutrition and
practitioners around the the unique functions of nutrition and dietetics terminology, the Standardized
world use the Nutrition Care dietetics practitioners and supports Language Task Force, composed of 12
Process Terminology (NCPT) the research on nutrition and dietetics Academy member volunteers supported
to communicate the Nutrition care. This article replaces previous in- by terminology consultants and Academy
Care Process (NCP).1 In this article, formation on the use of the NCPT. staff, undertook development of termi-
nutrition and dietetics practitioners or nology for the NCP step Nutrition Diag-
professionals; dietitians; dietitians- nosis. Sixty-two Nutrition Diagnosis
nutritionists; and dietetic technicians, A DECADE OF USE AND terms were published in 2006.7 Subse-
registered, are collectively referred to DEVELOPMENT quently, the Task Force developed terms
as professionals. The NCPT is a stan- The NCPT, formerly known as the Inter- for the Nutrition Assessment, Nutrition
dardized terminology or controlled vo- national Dietetics and Nutrition Termi- Intervention, and Nutrition Monitoring
cabulary that complements the NCP, a nology (IDNT), was designed to meet the and Evaluation NCP steps. As a result, an
systematic problem-solving roadmap definition of a controlled vocabulary as official terminology that supported all
for planning and providing nutrition determined by the National Library of four steps of the NCP was published in
and dietetic care to individuals and Medicine.3 This means that the NCPT is a 2008.8 Currently, the NCP Outcomes
populations, and researching related system of terms organized in a hierar- Research Committee (NCPROC) of the
outcomes. Recently, a scheduled up- chical structure, with definitions and Academy oversees the development and
date of the NCP and Model (NCPM) cross-references used to index and maintenance of the NCPT with support
was published.2 The NCPM is the retrieve a body of literature in a biblio- from its workgroups (ie, International,
graphic representation of the NCP. The graphic, factual, or other database.4 The Advisory, and Classification) and in
NCP includes four steps that collec- NCPT was initially presented as a docu- collaboration with the Council on
tively describe the unique contribu- mentation tool for electronic health re- Research, Informatics, and Interopera-
tions of nutrition and dietetics cords (EHRs).5 Of note, the IDNT became bility and Standards Committees. The
practitioners. These steps are Nutrition the NCPT in 2014 to emphasize its link- complete NCPT (electronic NCPT [eNCPT])
Assessment and Reassessment, Nutri- age to the NCP. Today, the NCPT is a tool is released once a year and is available
tion Diagnosis, Nutrition Intervention, that standardizes nutrition and dietetics- through a web-based platform.1 A book,
and Nutrition Monitoring and Evalua- related communication beyond the the Abridged Nutrition Care Process Termi-
tion. A companion to the model update health care setting and is capable of nology (NCPT) Reference Manual: Stan-
publication, this article reviews the demonstrating quality of care and related dardized Terminology for the Nutrition Care
background of the NCP and describes outcomes. Process9 provides a select subset of NCP
the current state and ongoing enhance- In 2003, the Academy of Nutrition terms in print form.
ments of the NCPT.2 A further aim is to and Dietetics (Academy), formerly the The NCPT has developed in several
American Dietetic Association, aspects since its original launch. Several
completed a review of defined health international nutrition and dietetics or-
*Certified in Canada. care vocabularies to evaluate whether ganizations work collaboratively with

Certified in New Zealand.
§ these existing vocabularies adequately the Academy to support, adopt, and
Certified in Sweden.
¶ communicated the scope of nutrition translate the NCPT into different lan-
Certified in Australia.
care. Although several of the defined guages (Figure 1).10-12 Also, the appli-
terms at the time included nutrition- cation and related experiences with
2212-2672/Copyright ª 2019 by the focused terms, they did not describe NCPT have been reported in various
Academy of Nutrition and Dietetics. the complete range or the specific ac- practice and education settings.13-19 To
https://doi.org/10.1016/j.jand.2018.10.025
tivities performed by nutrition and di- better communicate nutrition care in
Available online 16 January 2019
etetics practitioners.6 practice and research, processes for

840 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS ª 2019 by the Academy of Nutrition and Dietetics.
FROM THE ACADEMY

Figure 1. International translations timeline. Countries that translated during the same year are listed in alphabetical order. *Country that
has conducted regular updates of the Nutrition Care Process Terminology. ND¼nutrition diagnosis. NI¼nutrition intervention.

modifying the NCPT have been imple- domains, classes, and subclasses nutrition and dietetics practitioners use
mented by the NCPROC that ensure a (Figure 2). An extensive number of NCP NCPT to communicate care with preci-
responsive environment for NCPT terms have reference sheets that serve sion.23,25 Examples of the application of
enhancement. As a result, the number as a descriptive profile for the term. NCP using NCPT in a variety of practice
of NCPT terms has expanded to support NCP terms on the reference sheets are settings are illustrated in Figure 3.
the range of skills and roles of nutrition defined in the case that they do not In a dynamically evolving health care
and dietetics practitioners. Synonyms exist in the international clinical ter- environment, the vision for the NCP and
have been added that embrace practice minology standards described else- NCPT is to facilitate communication
and cultural sensitivities. Because the where in this article. within and among health care systems
NCPT is among many health care ter- The purpose of the NCPT is to provide for outcomes research and quality
minologies, its terms are submitted to an accurate and specific description of improvement. Thus, the NCPT is an
larger interdisciplinary international the services that nutrition and dietetics important tool to advance the field of
clinical terminology standards such as practitioners deliver, and the investiga- nutrition and dietetics, related educa-
Systematized Nomenclature of tion of resulting outcomes. This achieves tion, research, and policy as the updated
Medicine-Clinical Terms (SNOMED-CT) a common understanding not only logic model guiding terminology
and Logical Observation Identifiers among nutrition and dietetics practi- development demonstrates (Figure 4).
Names and Codes (LOINC) on an tioners, but also outside the profession,
ongoing basis.20,21 In recent years, the including clients (individuals or pop-
NCPT has been used in practice-focused ulations) and other disciplines. Another Acceptance and Adoption
nutrition research showing the efficacy substantial purpose of the NCPT is that it The NCPT supports application of the
and degree of application of the NCP, as provides a means to show the influence NCP in numerous countries. The Euro-
well as adherence to evidence-based of nutrition care on outcomes and quality pean Federation of the Associations of
nutrition practice guidelines.18,22-24 of care to health professionals and the Dietitians Report on Knowledge and Use
public. Regardless of chosen note format of a Nutrition Care Process and Stan-
(eg, the traditional Subjective, Objective, dardized Language by Dietitians in
NCPT: THE STANDARDIZED Assessment, Plan system or the Assess- Europe11 reported that there were
TERMINOLOGY OF NUTRITION ment, Diagnosis, Intervention, Moni- positive attitudes for the use of a
AND DIETETICS toring, Evaluation system) or other standardized terminology that de-
The NCPT is organized by NCP steps means of documentation/reporting scribes the NCP. At the time of this
and within each step it is organized by based on policy or personal preference, survey, seven European countries

May 2019 Volume 119 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 841
FROM THE ACADEMY

NCP STEP DOMAIN HIGHLIGHT ON NEW TERMS


Food and Nutrition-Related
History (381 terms)
Assessment and
Reassessment

Anthropometric
Measurements (88 terms)
(1,083 terms)

Biochemical Data, Medical


Tests, and Procedures
(228 terms)

Nutrition Focused Physical


Findings (348 terms)

Client History (38 terms)

Detail Showing Malnutrition (undernutrition) Terms


Malnutrition (undernutrition) (NC-4.1)
Starvation related malnutrition NC-4.1.1
Moderate starvation related malnutrition NC-4.1.1.1
Diagnosis (166 terms)

Severe starvation related malnutrition NC-4.1.1.2


Intake (111 terms)
Chronic disease or condition related malnutrition NC-4.1.2
Moderate chronic disease or condition related malnutrition
NC-4.1.2.1
Clinical (38 terms) Severe chronic disease or condition related malnutrition
NC-4.1.2.2

Acute disease or injury related malnutrition NC-4.1.3


Behavioral/ Environmental Moderate acute disease or injury related malnutrition
(17 terms) NC-4.1.2.1
Severe acute disease or injury related malnutrition
NC-4.1.2.2

Non illness related pediatric malnutrition NC-4.1.4


Mild non illness related pediatric malnutrition NC-4.1.4.1
Moderate non illness related pediatric malnutrition NC-4.1.4.2
Food and/or Nutrient Severe non illness related pediatric malnutrition NC-4.1.4.3
Intervention (400 terms)

Delivery (302 terms)

Illness related pediatric malnutrition NC-4.1.5


Nutrition Education Mild illness related pediatric malnutrition NC-4.1.5.1
(6 terms) Moderate illness related pediatric malnutrition NC-4.1.5.2
Severe illness related pediatric malnutrition NC-4.41.5.3
Nutrition Counseling
(16 terms)

Coordination of Nutrition
Care by a Nutrition Detail Showing Populaon Based Nutrion Acon Classes
Professional (9 terms)
Populaon Theorecal Frameworks (P-1)
Population Based Nutrition
Action (67 terms) Populaon Strategies (P-2)

Populaon Sengs (P-3)

Populaon Sectors (P-4)


Food and Nutrition-Related
Evaluation (1,045 terms)

History (381)
Monitoring and

Anthropometric
Measurements (88 terms)

Biochemical Data, Medical


Tests, and Procedures
(228 terms)

Nutrition Focused Physical


Findings (348 terms)

Figure 2. Nutrition Care Process (NCP) Terminology hierarchy.

842 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2019 Volume 119 Number 5
May 2019 Volume 119 Number 5

Case Public Health Foodservice Long-Term Care Acute Care Nonacute Care
NCP Situation: Women of Situation: In a Situation: Daughter of Situation: Hospitalized Situation: Female teacher with
reproductive age found with natural disaster, personal care home resident female teacher with complaint of undesired weight
low Hgba and iron-deficient it is estimated concerned with mother’s complaint of undesired gain referred by hospital RDNb
diet that 5 d are food intake. Resident has weight gain. Reason for (Same person as in Acute Care)
needed to repair swallowing difficulties admission: emergency
and restore appendectomy
potable water
supply

Assessment Food Intake: infrequent Availability of Food intake: Food consumption Energy intake: >2,200 kcal/d, Weight Management RDN
consumption of iron-rich potable water: a reported to be <50% of (9,200 kJ/d) Age: 45 y Stated validates assessment data
foods, Mineral element intake : 3-d supply of 1 meals. Reduced intake height: 5 ft 5 in (163 cm), received from hospital RDN
<67% EARc for iron for gender gal (4L)/person/ progresses throughout the Stated weight: 190 lb (86 kg) via a Transition of Care
and age, d as day with fatigue and Body mass index: 32.4, Obese. (C-CDAe) document. (In
Nutritional anemia profile: recommended increased signs/symptoms of Meal snack pattern: Eats practice this means that all
Hgb: high incidence of values by EPAd is dysphagia. when not hungry. Types of data from the acute care
below the population available Weight loss: 7 lb (3.2 kg) in food meals: High-fat foods setting (acute care case in this
reference standard (40% of past month (5% weight loss) frequently, Weight gain: 60 lb Figure) were transmitted as
women of reproductive age) Measured Weight: 148 lb (67 (27 kg) in 24 mo, Readiness to documented to the nonacute
Comparative standards: kg) change nutrition related care setting.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Estimated mineral needs: EAR Nutrition-focused physical behavior: Contemplation,


for iron for women aged findings: Mild/moderate loss expresses concern about
19-50 y¼8.1 mg/d of muscle mass health status
Hgb >120 g/L Diet: Minced and moist Comparative standards: Total
Comparative standards: Total estimated energy needs in
estimated energy needs in 24 h: 1,500 kcal (6,300 kJ),
24 h: 1,500 kcal (6,300 kJ), Method for estimating total

FROM THE ACADEMY


Total estimated protein needs energy needs: Mifflin-St Jeor
in 24 h: 80 g protein/d
Method for estimating total
energy needs: 22 kcal/kg,
1.2 g protein/kg
(continued on next page)
Figure 3. Terminology applications in a variety of practice settings. Nutrition Care Process Terminology terms are presented in boldface italic type.
843
FROM THE ACADEMY
844

Case Public Health Foodservice Long-Term Care Acute Care Nonacute Care
NCP Situation: Women of Situation: In a Situation: Daughter of Situation: Hospitalized Situation: Female teacher with
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

reproductive age found with natural disaster, personal care home resident female teacher with complaint of undesired weight
low Hgba and iron-deficient it is estimated concerned with mother’s complaint of undesired gain referred by hospital RDNb
diet that 5 d are food intake. Resident has weight gain. Reason for (Same person as in Acute Care)
needed to repair swallowing difficulties admission: emergency
and restore appendectomy
potable water
supply

Diagnosis P: Inadequate mineral intake: Iron Limited access to Malnutrition Excessive energy intake Undesirable food choices
(demonstrative related to potable water related to related to related to
example only)f infrequent consumption of related to inadequate oral intake consuming high-fat foods consuming high fat foods
E: iron-rich foods lack of disaster as evidenced by when not hungry when not hungry
S: as evidenced by planning resident consuming <50% of as evidenced by unintended as evidenced by
low dietary iron consumption as evidenced by meals, 5% weight loss, weight gain of 60 lb (27 kg) in unintended weight gain of
(<67% EAR) and low Hgb <5 d supply of 1 evidence of muscle wasting 24 mo and energy intake 60 lb (27 kg) in 24 mo and
(<120 g/dL) in 40% of gal (4 L) /person/ (SGAg B) and reports of exceeding total estimated energy intake exceeding total
women of reproductive age d fatigue and dysphagia energy needs by estimated energy needs by
700 kcal/d (2,900 kJ/d) 700 kcal/d (2,900 kJ/d)
Intervention Mass communication to Team meeting: Nutrition Prescription: 1,500 Nutrition prescription: 1,600 Nutrition prescription: 1,600
promote Food environment with food kcal 80 g protein/d, purèed kcal/d (6,700 kJ/d), Health kcal/d (6,700 kJ/d), Social
change in Communities, production diet, Meals and snacks: belief model, Motivational learning theory, Goal setting,
neighborhoods and families manager, water Purèed food Level 4 Green, interviewing, Referral to RDN Recommended modifications:
sector. vendors, Moderately thick liquid Level with different expertise. lower-fat snack choices.
Goal: 50% Reduction in materials 3 Yellow Goal: Make appointment with Goal: Altered eating habits
anemia in women of manager to plan Food and Nutrient Delivery: weight management RDN result in weight loss of 5% of
reproductive ageh action points Change diet order to purèed before discharge current body weight
Goal: 5-d Supply with fortified foods and
potable water to between-meals snacks.
provide 1 gal Implement medication
(4 L)/d/person nutrition supplement pass
May 2019 Volume 119 Number 5

program.
Collaboration with other
providers: Nursing to monitor
tolerance to purèed diet
(continued on next page)
Figure 3. (continued) Terminology applications in a variety of practice settings. Nutrition Care Process Terminology terms are presented in boldface italic type.
May 2019 Volume 119 Number 5

Case Public Health Foodservice Long-Term Care Acute Care Nonacute Care
NCP Situation: Women of Situation: In a Situation: Daughter of Situation: Hospitalized Situation: Female teacher with
reproductive age found with natural disaster, personal care home resident female teacher with complaint of undesired weight
low Hgba and iron-deficient it is estimated concerned with mother’s complaint of undesired gain referred by hospital RDNb
diet that 5 d are food intake. Resident has weight gain. Reason for (Same person as in Acute Care)
needed to repair swallowing difficulties admission: emergency
and restore appendectomy
potable water
supply

Monitoring and Food Intake, Mineral element Availability of Food intake, Diet Order: Meal Readiness to change nutrition Body mass index, Meal snack
evaluation intake, potable water: observation by nursing related behavior: made pattern, Types of food meals.
Nutritional anemia profile: Water supply of reports tolerance and appointment with weight Eating fruit and whole grain
Hgb: After 3 y, modestly 1 gal (4 L)/ acceptance of diet. management RDN before snacks when hungry, weight
increased consumption of person/d for 5 d Fluid/beverage intake: 95% discharge reduction, confident of ability
iron-rich foods (<EAR) and achieved consumption of commercial Indicator: Adherence to continue
incidence of low Hgb (Hgb Indicator: Water (prepackaged) beverage Criterion: Make appointment Indicator: Body mass index
<120 g/L) not trending supply Weight change: weight gain with weight management Criterion: Body mass index
toward reduction. Program Criterion: at least 3% RDN <31.7
modified 1 gal (4 L)/ Indicator: Percent intake of Indicator: weight reduction
Indicator: Dietary intake of person/d for 5 d served meals snacks, and Criterion: 5% weight
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

iron beverages reduction of current body


Criterion: >EAR Criterion: at least 95% weight
Indicator: Hgb Indicator: Weight gain
Criterion: Hgb >120 g/L Criterion: weight gain by 3%
a
Hgb¼hemoglobin.
b
RDN¼registered dietitian nutritionist.
c
EAR¼ Estimated Average Requirement.

FROM THE ACADEMY


d
EPA¼Environmental Protection Agency (https://www.epa.gov/sites/production/files/2015-03/documents/planning_for_an_emergency_drinking_water_supply.pdf).
e
C-CDA¼Consolidated Clinical Document Architecture.
f
PES¼Problem, Etiology, Signs, and Symptoms.
g
SGA¼Subjective global assessment.
h
http://www.who.int/nutrition/global-target-2025/en/.
Figure 3. (continued) Terminology applications in a variety of practice settings. Nutrition Care Process Terminology terms are presented in boldface italic type.
845
FROM THE ACADEMY
846

2003 Ultimate impacts (Part II, Status of Assumptions Stakeholders 2018 Ultimate Impacts
2008) Ultimate
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Impacts

Quality, cost-effective nutrition Ongoing  Nutrition is an essential component of  Health care consumers Safe, effective, efficient, person-
care delivered in partnership high quality health care for promotion  Academy members centered, timely, and equitable
with providers, agencies, and of health and prevention of disease  Academy BODc nutrition care delivered in
communities  Data are needed to research the pro-  Academy HODd collaboration with providers,
Nutrition care grows nationally Ongoing cess and outcomes of nutrition care  Other health care providers agencies, and clients
Standardized nutrition  Nutrition and dietetics professionals,  Health care payers Nutrition care improves the health and
language included in dietitian educators, and researchers will use  Legislators and regulators well-being of all people
education Realization and enhance a standardized nutrition  Health care researchers Standardized nutrition language
Ongoing maintenance and language  International health care termi- integral to nutrition and dietetics
updates of standardized  Nutrition and dietetics professionals, nology and information man- education
terminology accomplished by educators, and researchers continue to agement standards Robust maintenance and updates of
the Academya and/or partners Ongoing use and improve the NCP organizations standardized terminology
Evaluate a national data  Nutrition and dietetics professionals  International nutrition and accomplished by Academy and its
warehouse established for a and researchers use standardized ter- dietetics professionals and global partners
sustainable, reliable and useful minology in a database to perform organizations Popularize a sustainable, reliable,
database for Academy/ Realization outcomes management and targeted useful database for Academy and
dietitians/researchers research nutrition and dietetics research and
National, state, and local  Nutrition and dietetics professionals innovation
policies developed and improve effectiveness through Jurisdictional policies developed and
supported to foster nutrition collaboration supported to foster nutrition
practice, education, and Ongoing  Emphasis on people-centered, value- practice, education, and research
research based health care Support adoption of NCP and NCPT
Incorporate NCPb and into nutrition and dietetics practice
International Dietetics and Realization world-wide
Nutrition Standardized NCPTe is the essential element linking
Language in to dietetics technological innovations, and
practice worldwide achieving interoperability in
nutrition and dietetics at large
May 2019 Volume 119 Number 5

a
Academy¼Academy of Nutrition and Dietetics.
b
NCP¼Nutrition Care Process.
c
BOD¼Board of Directors.
d
HOD¼House of Delegates.
e
NCPT¼Nutrition Care Process Terminology.
Figure 4. Logic Model for standardized terminology. The goal is to provide data to foster nutrition and dietetics practice, education, research, and policy.
FROM THE ACADEMY

reported the use of IDNT. Recently, the culturally sensitive translation. terminology standard such as SNOMED-
nutrition diagnosis terms of NCPT were Change-management skills and lead- CT and LOINC. If a term is progressed to
mapped to the International Classifi- ership support are also needed for the Classification Workgroup and is
cation of Diseases as part of a national successful implementation.29,30 found to already exist in an interna-
project in Norway.26 Japan and South tional clinical terminology standard, the
Korea also adopted the IDNT.27,28 A Development and Submission term may be readily adopted without
recent global survey of NCP/NCPT Process additional development.
adoption and use has been completed The NCPT communicates the pro- If a proposed term is progressed to
and the results are being prepared for fession’s unique contribution to health the Classification Workgroup and is not
publication (personal communication care. The terminology grew from 62 found in existing international clinical
with Elin Lovestam, June 5, 2018). From Nutrition Diagnosis terms in 2006 to standards, then development work
the Academy’s Professional Assessment 712 NCPT terms in 2008. There are may be needed. When expert agree-
Survey, there is increasing trend of use currently about 1,700 terms (Figure 2) ment is reached on the proposed con-
of Academy resources related to NCP defining the four steps of the NCP. The tent, terms are approved by the
and NCPT from 2007 to 2017 (NCPRO terminology has globally evolved from NCPROC for inclusion in the next
Committee face-to-face meeting, June principles and initiatives to acknowl- release of the NCPT.31 Term and defi-
5, 2017). In this survey, 20% of re- edge community and public health nition development is a consensus
spondents use NCPT in structured EHRs nutrition and other specialty practices, among experts or expert practice
(predefined data elements to select and to achieve inclusion into stan- groups that reflects current nutrition
from), 45% in unstructured (free-text) dardized EHR terminologies (Figure 5). and dietetic practice and research.
EHRs, and 30% is a combination of Ongoing work to maintain the termi- Recent examples of this approach
structured and unstructured docu- nology for an ever-changing profession includes terms describing the etiology
mentation (NCPRO Committee face-to- is possible because of the valuable and severity of adult and pediatric
face meeting, June 5, 2017). These contribution of practitioners and con- malnutrition, International Dysphagia
data reflect that a large portion of tent experts and the improved process Diet Standardization Initiative terms,
practitioners are still documenting by which terms are developed. terms to support the Nutrition-Focused
electronically in free-text fields. It is Throughout the early development Physical Examination, and the
important to acknowledge that process, the Standardized Language Task Population-Based Nutrition Action
upgrading EHR technology to struc- Force sought term suggestions from intervention terms (Figure 5).
tured form is a major and challenging practitioners and subject matter experts. With the increase in international
change that requires resources and Forms were included within the IDNT NCPT use, NCPROC was restructured to
vested stakeholders. Academy survey books to encourage term submission ensure half the membership was based
data integrated with the awaited in- from users of the terminology. Term internationally. Likewise, the NCPROC
ternational survey will assist in devel- submitters provided a term definition, Advisory Workgroup, International
oping global strategies for NCP/NCPT reference sheet, and supporting evi- Workgroup, and Classification Work-
use and adoption. dence. Term refinement was a collabo- group contribute a global talent pool of
Difficulties and challenges of imple- rative process between submitters and subject matter experts. Thus, the NCPT
menting the NCPT have been identified an expert terminology consultant. The evolves with new and revised term
by several studies. Challenges with expert terminology consultant also pro- requests from a dynamic, international
implementation have included vided a recommendation for placement profession.
increased time requirement to use of the term within the terminology
NCPT, concern that other health pro- structure. This completed work was
fessionals will not read nutrition diag- submitted to the committee for inclusion Translation
nosis statements, limited number of in the terminology. The eNCPT has been translated from US
translations, concern that translation The submission process was modified English into seven languages and di-
or dialects may lead to mis- in 2014 to streamline the involvement of alects.10 The translations are available
interpretations of the terminology, and NCPROC, its supporting workgroups, to all eNCPT subscribers. The Academy
patient-centered experience data may and an expert terminology consultant. collaborates with international profes-
not be captured effectively (NCPRO The revised process evaluates term re- sional organizations such as associa-
Committee face-to-face meeting, July quests and modifications from groups of tions and or universities, and their
13, 2017).11 Results from a qualitative subject matter experts such as Academy translating team entities (eg, collabo-
study found that Swedish dietitians dietetic practice groups, Academy rators, consultants, or other appointed
expressed ambivalence toward the leaders, and NCPT users.31 professionals) in an effort to make the
terminology in that some terms, espe- Some important changes to the sub- NCPT a global language with interna-
cially in the environmental-behavioral mission process include an initial re- tional usage.32
domain of the Nutrition Diagnosis ter- view by the NCPROC to assess the Sweden completed its translation in
minology, were harsh or offensive to- term’s merit in nutrition and dietetics 2011 and has subsequently completed
ward patients.14 These surveys support practice before allocating consulting four updates. Experiences from Sweden
that implementation strategies should time or obtaining a review by the Clas- have shown the importance of creating
include education and training, incor- sification Workgroup to determine a work group of experienced dietitians
poration of terminology into docu- whether a proposed or modified term as well as having an ongoing dialogue
mentation tools for health records, and already exists in an international clinical and consensus building among the key

May 2019 Volume 119 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 847
FROM THE ACADEMY
848

Principles and initiatives Select NCPT examples


JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Reflect an International leaders, experts, and reviewers are integral to the NCPT Complex carbohydrate estimated intake in 24 h (g/day)
international maintenance and Committee processes.  Vitamin A estimated intake in 24 h in mg (micrograms)
perspective US and international standards are included in resources for:  BUNa (mg/dL or mmol/L)
 Measures  Creatinine measurement, serum (mg/dL or mmol/L)
 Laboratory units  Estimated daily glycemic load (number) Definition: The esti-
 Nutrient intake mated measure per day reflecting the quantity and type of all
carbohydrate consumed.
NCPb and NCPT are used in several countries. Definitions are developed to
 Purèed food Level 4 Green
incorporate new NCPT into standardized terminologies and for accurate
 Extremely thick liquid Level 4 Green
conceptual translation.
 Liquidized food Level 3 Yellow
The NCPROc Committee collaborated with the International Dysphagia Diet
 Moderately thick liquid Level 3 Yellow
Standardisation Initiative to develop NCPT diet terms and definitions so that
the Academyd could submit them to standardized terminologies.59
Take a people- New term synonyms were deemed necessary for terminology considered  Food and nutrition-related knowledge deficit synonym
centered approach overly judgmental.35 Limited food and nutrition-related knowledge
 Undesirable food choices synonym Unbalanced diet
 Physical inactivity synonym Limited physical activity
Recognize the Malnutrition was reclassified as a clinical condition with movement of the  Moderate chronic disease or condition related malnutrition
etiology nutrition diagnosis from the Intake domain to the Clinical domain for  Severe acute disease or injury related malnutrition
and severity of more accurate modeling of these conditions.  Mild nonillness-related pediatric malnutrition
malnutrition  Moderate illness-related pediatric malnutrition
(undernutrition) Malnutrition indicators from the Academy consensus papers for adults and  Temporalis muscle atrophy
pediatrics have been included in the NCPT reference material.60,61  Handgrip strength
 Head circumference for age z score
 Weight for length z score
Characterize nutrition Nutrition interventions at the institutional, community, and policy Population-based nutrition action
interventions in levels describe actions to address nutrition problems influenced by the  Social ecological model
populations environment in which people live, work, and play.  Social marketing
Fully integrating the Social Ecological Model, a new Nutrition interventions  Mass communications
 Food environment change
May 2019 Volume 119 Number 5

domain, aligned the NCPT with the Centers for Disease Control and
Prevention Health Impact Pyramid and the World Health Organization  Public policy change
Population Health Promotion Model, which was adopted in the Ottawa  Food production and provision settings
Charter on Health Promotion. 62-64
 Government settings
 Agriculture sector
 Communities, neighborhoods, families sector
(continued on next page)
Figure 5. Major principles and initiatives of Nutrition Care Process Terminology (NCPT).
May 2019 Volume 119 Number 5

Principles and initiatives Select NCPT examples

Represent content for Practitioner-led efforts to reflect their practice and research with neonatal,  Breastmilk feeding attempts in 24 h
specialized practice long-term care, inborn errors of metabolism, gastrointestinal disorder,  Docosahexaenoic acid estimated intake in 24 h
and community nutrition and public health populations are included in  Total fat from intravenous fluids
NCPT adding 781 assessment/monitoring and evaluation terms, 107  Total protein per kilogram estimated in 24 h
diagnosis, and 326 intervention terms since all 4 steps were published in  Phenylalanine, dried blood spot
IDNTe in 2008.5  Pressure injury of hip
 Excessive growth rate
 Consistent carbohydrate diet
 Modify composition of parenteral nutrition
 Modify route of parenteral nutrition
Clarify usage of The NCPRO Committee has responded to practitioner concerns and  Altered gastrointestinal function
terminology questions by:  Impaired nutrient utilization
Providing guidance for diagnoses associated with exocrine and  Intake of types of proteins inconsistent with needs
endocrine functions,  Predicted inadequate energy intake
Relocating an indicator for gluten from a carbohydrate to a protein  Predicted breastfeeding difficulty
diagnosis because of the protein in gluten responsible for the intolerance  Predicted food medication interaction
or allergy, and
Defining predicted nutrition diagnoses that are anticipated based on
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

observation, experience, or scientific reason.


Structure unique Removing the need for hierarchical terminology construction by creating  Potassium estimated intake in 24 h
nutrition data complete terms and submitting them to standardized terminologies (ie,  Serum potassium measurement
SNOMED CTf and LOINCg), each term is assigned a 5-digit Academy  Inadequate potassium intake
unique identifier.20,21 This facilitates data tracking in electronic record  Potassium modified diet
systems. While all terms in nutrition diagnosis and intervention have  Potassium supplement therapy
external mappings, work continues in assessment.  Estimated potassium needs

FROM THE ACADEMY


Ambiguous terms, such as suboptimal and less than optimal, have been  Growth rate below expected
replaced with more accurate labels.  Intake of types of fats inconsistent with needs (specify)
Terms that conveyed more than 1 idea have been separated for  Limited access to food
independent expression.  Limited access to potable water
 Measured weight
 Stated weight
 Loss of subcutaneous fat overlying the ribs
(continued on next page)
Figure 5. (continued) Major principles and initiatives of Nutrition Care Process Terminology (NCPT).
849
FROM THE ACADEMY

contacts (expert dietitians with var-

Referral to registered dietitian nutritionist with different


ied practice experiences and other
health care professionals) involved in
the translation.33 To be useful to
nutrition and dietetics practitioners, a
conceptual translation that is accu-
rate, unambiguous, linguistically cor-
rect, and consistent is needed.

Referral to community agencies/programs


Translating challenges include differ-
ences in culture, health care systems,
Inadequate pantothenic acid intake

Total fiber estimated intake in 24 h

legal issues, differences in the use of


Collaboration with other providers
Iliac crest abnormal prominence

nutrition and dietetics terms, and


Fruit servings estimated in 24 h

references to US-specific concepts in


Inadequate selenium intake

the terminology. Conceptual trans-


lation is facilitated by clear definitions
and supporting reference sheets.
The Academy welcomes translations
Select NCPT examples

of the eNCPT. To obtain acceptance


from the Academy to translate, trans-
lators need support from their national
expertise

dietetics association or equivalent


professional governing entities or uni-
versity. The responsibility for the
quality of the translation and associ-










ated costs lie with the translating or-


ganization. A concern for the future is
fruit servings, psyllium) not previously in standardized terminologies are

Some terms label procedures were revised to clarify them as nutrition and
Nutrition concepts (eg, loss of subcutaneous fat overlying the ribs, iliac crest
abnormal prominence), and substances (eg, pantothenic acid, selenium,

Figure 5. (continued) Major principles and initiatives of Nutrition Care Process Terminology (NCPT).

that the costs to complete an initial


translation, subsequent maintenance,
and access to the eNCPT may not be
affordable for dietetics associations or
other interested organizations in
developing economies. There is a need
for a sustainability model that facili-
tates and/or funds translations in less-
SNOMED CT¼Systematized Nomenclature of Medicine Clinical Terminology.

affluent countries.

SYNONYMS: THE GLOBAL


MOVE TOWARD PEOPLE-
CENTERED CARE
LOINC¼Logical Observation Identifiers Names and Codes.
now present for worldwide use.

The adoption of a people-centered


IDNT¼International Dietetics and Nutrition Terminology.

care approach, sometimes more


dietetic practitioner actions.

NCPRO¼Nutrition Care Process Research Outcomes.

narrowly referred to as patient-


centered or person-centered care, is
Academy¼Academy of Nutrition and Dietetics.

growing globally.34 This approach


includes providing an individual full
access to his or her health care in-
formation. The Organization for
Economic Co-operation and Devel-
opment has developed quality health
care indicators, including indicators
NCP¼Nutrition Care Process.
BUN¼Blood Urea Nitrogen.

to track patient-centered care, that


Principles and initiatives

allow comparisons across member


countries.35,36 The inclusion of
patient-centered health care mea-
sures into health care system per-
formance assessments has occurred
in many countries, including
Australia, Canada, Denmark, France,
Germany, Switzerland, the
Netherlands, New Zealand, United
b

g
e
a

Kingdom, and the United States.34

850 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2019 Volume 119 Number 5
FROM THE ACADEMY

Leadership and cultural trans- submission process, a number of syn- an overarching International Edition.20
formation are part of the patient- onyms for diagnostic terms within the LOINC has a single edition with
centered care journey.37 In countries Behavioral-Environmental Domain translations.21
where clients have full access to their were approved and included in the The widespread transition to EHRs
health record, it is very important to 2016 eNCPT release (Figure 6). Syno- has made it apparent that there is a
use terminology that is not perceived nyms can be used interchangeably in need to have NCPT incorporated into
to be harsh or offensive. There is place of the original term without the SNOMED-CT International Edition.
greater recognition for the need of altering the meaning. This would make NCPT available to all
people to be considered as individuals entities using SNOMED-CT. Recently,
with varied needs and not as clinical dietetics associations from Australia,
symptoms. The choice of words used NCPT INCLUSION IN CLINICAL Brazil, Canada, Denmark, Israel,
during an episode of care ought to TERMINOLOGY AND Mexico, New Zealand, Norway,
reflect this philosophy. A psychologist’s ELECTRONIC HEALTH Switzerland, Sweden, and the United
view regarding successful use of stan- INFORMATION MANAGEMENT States requested inclusion of NCPT
dardized language is that it should STANDARDS terms into the International Edition of
correspond to situations in practice, The Academy has been submitting NCPT SNOMED-CT. This request was
have internal coherence, and intuitive terms to SNOMED-CT and LOINC since accepted and in July 2018 all NCPT
appeal to users.38 2011, and has developed electronic terms that were in the US edition
The provision of care and the language health information management stan- are now available in the SNOMED-CT
describing that care needs to be dards for Health Level 7 (HL7).20,21,40 International Edition.20 This is a major
respectful and responsive to individual SNOMED-CT and LOINC are clinical ter- step forward for continued interna-
preferences and values. With the global minology standards required for use in tional NCPT availability and adoption.
adoption and implementation of NCPT, US EHRs and similarly used in many The Academy maps and models the
the terminology needs to communicate other countries. Both standards are used NCPT to SNOMED-CT and LOINC on an
the care provided to culturally and internationally in EHRs. Generally ongoing basis. Mapping and modeling
linguistically diverse populations. Feed- speaking, SNOMED-CT terms encompass is a process to confirm that an equiv-
back from international surveys has terms from all NCP steps. LOINC includes alent relationship with a term exists
indicated the desire for terms that are primarily quantitative Nutrition Assess- in a terminology standard and ensures
more patient-centered. The 2014 ment and Nutrition Monitoring and that NCPT communicates the same
Australian NCPT Implementation Survey Evaluation terms. meaningful information and signifi-
showed improvement in NCPT attitudes, In the United States, terminology cant facts in SNOMED-CT or LOINC.
knowledge, and use over time.39 In that standards also facilitate coding the The resulting database and available
longitudinal survey, free-text comments financial value of care for procedures nutrition standards are used by de-
were collected to understand the chal- and services using Current Procedure velopers to match accurately NCPT to
lenges or barriers related to NCPT use, in Terminology of the American Medical SNOMED-CT or LOINC terms when
particular areas of practice. The dietitian Association41 and Healthcare Common designing an EHR.47 This may not
respondents’ comments included gen- Procedure Coding Systems G-codes.42 appear as a point of interest to nutri-
eral sentiments such as, “I would cringe These codes are maintained jointly by tion and dietetics professionals at
to write.,” “Some of the terminology is the alpha-numeric editorial panel with first. However, in EHRs the NCPT is
quite derogatory of the client/patient,” participation from the Centers for what the user sees and uses upfront
“An impersonal way of describing an Medicare and Medicaid Services and when they document and in the back
interaction” and, “Culturally words have other payer coding schemes.43 As part end are the SNOMED terms. EHRs
slightly different meanings. I change of SNOMED-CT and LOINC, NCPT pro- store SNOMED data for later reporting
some words when I deem the language vides terms useful in the United States and research. Thus, this matching be-
judgmental.” for coding social determinants of tween NCPT and SNOMED is a neces-
Synonym submissions from New health from nonphysician clinical sary foundation to be able to conduct
Zealand have provided alternatives to documentation using the International large-scale quality improvement such
the words deficit and inability. Specif- Classification of Diseases.44,45 as reporting on electronic quality mea-
ically, “Self-monitoring deficit,” “Food- The submission of NCPT to clinical sures, and/or NCP-related research. Pro-
and nutrition-related knowledge terminology standards started with fessionals are encouraged to advocate for
deficit” and, “Inability to manage self- nutrition assessment terms to meet an NCPT matching to SNOMED at their
care” are examples of terms that could urgent regulatory standard for EHRs in workplace EHR and work proactively
make an individual feel pessimistic, the United States.46 A consequence of with information technology staff to
discouraged, or embarrassed. An in- this process was that submissions of make this happen.
dividual’s personal strengths and NCPT to the International Health Inclusion of NCPT in the clinical ter-
capability may be overshadowed by a Technology Standards Development minology standards facilitates repre-
perceived critical expression. The syn- Organization, now SNOMED Interna- sentation of NCPT in electronic health
onym limited for inability is less judg- tional, were for the most part available information management standards
mental, more empathetic, and is in the US edition of SNOMED-CT and such as those of HL7.40 This represen-
constructive with a positive regard for not other countries. SNOMED-CT has tation is fundamental to the interop-
the individual. Utilizing the term multiple country editions in addition to erability of electronic health data and

May 2019 Volume 119 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 851
FROM THE ACADEMY

providing data for research (Figure 4).


Behavioral and Environmental Domain
As described in the NCP model update,2
a data aggregation platform, the Acad-
Knowledge and Beliefs emy of Nutrition and Dietetics Health
NCP Term Synonym Informatics Infrastructure (ANDHII),
the architecture of which contains the
Food and nutrition-related knowledge Limited food and nutrition-related
NCPT, was used in studies to “explore
deficit knowledge the feasibility of validating malnutri-
Self-monitoring deficit Limited self-monitoring tion diagnostic criteria”22 and “inves-
Undesirable food choices Unbalanced diet tigate the influence of evidence-based
Physical inactivity Limited physical activity nutrition practice guidelines for the
Inability to manage selfcare Limited ability to manage self-care prevention of diabetes on both practice
Impaired ability to prepare food/meals Limited ability to prepare food/meals patterns and patient outcomes.”18
ANDHII is forging new frontiers glob-
Figure 6. Nutrition Care Process (NCP) Terminology-approved synonyms can be used ally. ANDHII is being increasingly used
interchangeably in place of the original term without altering the meaning of the in nutrition research, education, and
term. NCP¼Nutrition Care Process. clinical and public health settings in
the United States and around the
records. Interoperability aims to pro- standard available from HL7 that defines world. This web-based NCPT tool can
vide a seamless, secure flow of mean- the necessary content and messaging for be especially helpful in settings where
ingful electronic information to nutrition and dietetics-related documen- the EHR is not structured yet to capture
improve care (Figure 7). tation. ENCPRS relies on NCP and NCPT for nutrition care and/or in public health
To foster nutrition care across care set- content. Also, in the United States, work is settings where a nutrition-focused
tings in the United States, the Academy underway to develop an HL7 standard for evaluation framework is needed. Edu-
provides routine input on nutrition transition of care documentation that in- cators use ANDHII to teach future cli-
informatics developments and related cludes templates for describing nutrition nicians in classrooms, internship
needs to the federal Office of the National care plans using NCP and NCPT. Termi- settings, and/or student-led clinics.
Coordinator of Health Information Tech- nology standards and data management ANDHII-focused activities empower
nology. This input is aimed to update the are essential structures to ensure inter- students to enhance their informatics
Interoperability Standards Advisory.47,48 operability among EHRs (Figure 7). skills, apply their NCPT in practice
A recent major development is the revi- conditions, and monitor the efficacy of
sion of the Electronic Nutrition Care Pro- their work. Other data aggregation
cess Record System (ENCPRS) for NCPT IN RESEARCH tools that contain NCPT content can
international use. The ENCPRS is a func- The NCPT as a structured terminology also be employed in research or quality
tional electronic health data management has begun to demonstrate its utility in improvement projects. Leveraging the

NCP and NCPT Data aggregation


Terminology/electronic health information management standards (e.g.Health Information
(SNOMED CT, LOINC/HL7) Exchange [HIE], Academy
of Nutrition and Dietetics
Health Informatics
Infrastructure [ANDHII])
Hospitalized obese female complains of unwanted weight gain, Coded value
referred to outpatient RDN with weight management expertise Quality improvement
Practiced based
research

Transition of care document


Improve
NCP and NCPT
care
Terminology/electronic health information management standards
(SNOMED-CT, LOINC/HL7)

Data aggregation
(HIE, ANDHII)
Obese female referred from hospitalization desires weight Coded value, QI
management care Practiced based
research
Figure 7. Interoperability schema. NCP¼Nutrition Care Process. NCPT¼Nutrition Care Process Terminology. SNOMED CT¼
Systematized Nomenclature of Medicine Clinical Terminology. LOINC¼Logical Observation Identifiers Names and Codes.
HL7¼Health Level 7 International. RDN¼registered dietitian nutritionist.

852 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2019 Volume 119 Number 5
FROM THE ACADEMY

data derived from NCPT is an avenue to research is NCPT acceptance by clients CONCLUSIONS
demonstrate effectiveness of nutrition and other health care providers. Over the past decade, the Academy has
and dietetics care. The need for structured diagnosis successfully pioneered a standardized
etiologies in the NCPT is being terminology to communicate the NCP
explored. Recent research demon- performed by nutrition and dietetics
GOING FORWARD strates that there is little agreement in practitioners. NCPT has been adopted,
The adoption and consistent use of the etiology selection among professionals implemented, and enhanced by inter-
NCPT promotes and strengthens nutri- when assessing nutrition-related data national professionals and organizations.
tion communications among health from the same client.55 A specific NCPT has been embraced by terminol-
professionals, their clients, and other nutrition diagnosis term may be ogy and health information manage-
customers. Several of the 2008 aspira- related to a variety of etiologies. It is ment standards. The terminology has
tions and goals for the NCPT have been the etiology that primarily determines grown to include specialty practices and
realized (Figure 4). These include the the intervention to resolve or mitigate varied practice settings as well as
incorporation of NCPT into EHRs and nutrition diagnoses.2 Being able to link culturally sensitive synonyms. NCPT
standardized clinical terminologies to nutrition diagnosis etiologies or etiol- growth is supported by a responsive
communicate nutrition care. Also, ogy categories and efficacious in- process to accommodate new terms that
expansion and revisions have occurred terventions would be useful in practice. address inevitable practice changes.
due to changes in the field of nutrition Descriptors that define the status of Research tools have been created to
and dietetics. The role of NCP and NCPT diagnosis resolution are being explore NCPT implementation, its utility
in informatics is now better appreci- developed. in describing the value of nutrition and
ated as NCPT becomes a part of clinical The documentation of the interven- dietetics practice, and the effectiveness
terminology and electronic health in- tion step needs to be further refined. in communicating quality practice that
formation management standards. The The intervention consists of the plan improves the health of communities. The
high interest in international trans- and the implementation. The plan need for training and continuing educa-
lation, adoption, and enhancement of (which includes the nutrition pre- tion regarding NCP and NCPT is ongoing.
NCPT continues to grow. Further scription and goals) and the imple- NCPT has become internationally essen-
development of the NCPT in the areas mentation of the plan could be further tial to the field of nutrition and dietetics,
of diagnosis etiology, nutrition assess- defined, structured, and quantified to intersecting technology, practice, and
ment and monitoring, and evaluation assist professionals in designing research for innovation and discovery.
status is needed. Standardization of measurable and comparable in-
etiologies will help reveal which types terventions. Also, defined scales to References
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AUTHOR INFORMATION
W. I. Swan is a past chair of the Nutrition Care Process Research Outcomes Committee, a member of the Classification Workgroup of the Academy
of Nutrition and Dietetics, and a retired dietitian based in Ranchos de Taos, NM. D. G. Pertel is an expert terminology consultant for the Nutrition
Care Process Terminology, and principal, Pertel Nutrition Consulting, Brookline, MA. B. Hotson is a member, Nutrition Care Process Research
Outcomes International Workgroup of the Academy of Nutrition and Dietetics, and a regional clinical manager, acute care, nutrition and food
services, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; at the time of the study, she was a member, Nutrition Care Process
Research Outcomes Committee. L. Lloyd is chair, Nutrition Care Process Research Outcomes Committee, a member, Nutrition Care Process
Research Outcomes International Workgroup of the Academy of Nutrition and Dietetics, and a senior renal dietitian, Department of Nutrition and
Dietetics, Auckland City Hospital, Auckland, New Zealand. Y. Orrevall is a member, Nutrition Care Process Outcomes International Workgroup of
the Academy of Nutrition and Dietetics; head of research and development, Education and Innovation, Function Area Clinical Nutrition, Kar-
olinska University Hospital, Stockholm, Sweden; and an associated researcher, Department of Learning, Informatics, Management, and Ethics,
Karolinska Institute, Stockholm, Sweden. N. Trostler is a member, Nutrition Care Process Research Outcomes International Workgroup of the
Academy of Nutrition and Dietetics, and a professor emeritus, Faculty of Agriculture, Food, and Environmental Sciences, Hebrew University of
Jerusalem, Rehovot, Israel; at the time of the study, she was a member, Nutrition Care Process Research Outcomes Committee of the Academy of
Nutrition and Dietetics. A. Vivanti is chair, Nutrition Care Process Research Outcomes International Workgroup of the Academy of Nutrition and
Dietetics; vice chair, Nutrition Care Research Outcomes Committee; and a research and development dietitian, Department of Nutrition and
Dietetics, Princess Alexandra Hospital Brisbane, Brisbane, Queensland, Australia; and senior lecturer, School of Human Movement and Nutrition
Studies, University of Queensland, Brisbane, Queensland, Australia. K. B. Howarter is principal, Ms. Nutrient Food and Nutrition Consulting
Services, Evanston, IL; at the time of the study, she was director, Nutrition Care Process, Research International Scientific Affairs, Academy of
Nutrition and Dietetics, Chicago, IL. C. Papoutsakis is a senior director, Data Science Center, Research International Scientific Affairs, Academy of
Nutrition and Dietetics, Chicago, IL.
Address correspondence to: Constantina Papoutsakis, PhD, RD, Academy of Nutrition and Dietetics, 120 S Riverside Plaza, Suite 2190, Chicago, IL
60606. E-mail: cpapoutsakis@eatright.org
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
C. Papoutsakis is an employee and D. G. Pertel is a consultant, Academy of Nutrition and Dietetics, Chicago, IL, which has a financial interest in
the Nutrition Care Process Terminology.
FUNDING SUPPORT
The Academy of Nutrition and Dietetics is the source of funding for the present update on the Nutrition Care Process Terminology. The authors
and experts who conducted the update on the Nutrition Care Process Terminology had complete autonomy during all stages of the update and
writing of the present manuscript.
AUTHOR CONTRIBUTIONS
All authors made substantial contributions to the conception of the work, co-drafted the initial draft, and revised it critically for important in-
tellectual content. W. I. Swan and C. Papoutsakis edited the manuscript post review.

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