The Standardized Language of Dietetics
Validation and Revision
Documentation of Nutrition Care
Update: Guidelines for defining the legal health record for disclosure purposes.
- •Nutrition-related assessment data, including pertinent food and nutrition history, biochemical data, medical tests and procedures, anthropometric measurements, nutrition-focused physical exam findings, and client history. The assessment may also include comparing data with pertinent standards.
- •A clear concise statement of nutrition diagnosis(es) written in the general format: “Diagnosis” related to “etiology” as evidenced by “signs and symptoms” where a term from the most current version of the Nutrition Diagnosis Terminology is used to describe the problem. A nutrition diagnosis is the current impression of an RD. Therefore, it may be changed or revised as new information becomes available. The patient may have more than one nutrition diagnosis or the words “no nutrition diagnosis at this time” may be documented in the medical record if the assessment indicates that no nutrition problem currently exists that warrants a nutrition intervention.
- •A description of the nutrition intervention is implemented to further the patient's/client's/group's progress toward the nutrition prescription, which is written by a registered dietitian to describe a patient's individualized needs. The intervention is linked to a specific nutrition diagnosis. Failure to link nutrition intervention to nutrition diagnosis has been identified as a deficit in existing documentation systems (15). Thus, each intervention is planned and accompanying goals are established with the patient/client/group.
- •A description of the nutrition monitoring and evaluation is used to identify patient/client outcomes relevant to the nutrition diagnosis and intervention plans and goals. The change in specific nutrition outcome indicators can be measured and compared to previous status, nutrition intervention goals, or reference standards.
Reimbursement and Regulation
Incorporation into Other Controlled Vocabularies
Using the Standardized Language and Electronic Health Records in Research
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- International Dietetics and Nutrition Terminology (IDNT) Reference Manual.American Dietetic Association, Chicago, IL2008
- Electronic health record: Where does nutrition fit in?.J Am Diet Assoc. 2006; 106: 1688-1695
- Glossary.(National Library of Medicine Web site)Accessed July 10, 2008)
AMA Physician ICD-9-CM 2008, Volumes 1 & 2. Chicago, IL; 2008.
- CPT® 2008 Professional Edition.American Medical Association, Chicago, IL2008
- Medicare medical nutrition therapy CPT codes and definitions.(American Dietetic Association Web site)Accessed October 29, 2007)
- Nursing Diagnosis: Application to Clinical Practice.11th ed. Lippincott Williams and Wilkins, Conshohocken, PA2005
- Guide to Physical Therapist Practice.2nd ed. American Physical Therapy Association, Fairfax, VA2003
- The International Classification of Functioning, Disability and Health (ICF) in clinical practice.Semin Speech Lang. 2007; 28: 241-243
- Logic Model Development Guide.W.K. Kellogg Foundation, Battle Creek, MI2004
- Reliability of nutrition diagnostic labels when used by registered dietitians at three levels of practice.J Am Diet Assoc. 2006; 106: A12
- Update: Guidelines for defining the legal health record for disclosure purposes.Accessed October 24, 2007)
- Guidelines for Recording Nutritional Information in Medical Records.in: Handbook of Clinical Dietetics. American Dietetic Association, Chicago, IL1981: 113-118
- A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes.J Am Diet Assoc. 2004; 104: 1878-1884
- Biomedical Informatics.in: Jones and Bartlett Publishers, Boston, MA2007: 1-7
- Toward a national framework for the secondary use of health data: An American Medical Informatics Association white paper.J Am Med Inform Assoc. 2007; 14: 1-9
This article was written by the Writing Group of the Nutrition Care Process/Standardized Language Committee.