Wednesday, April 23, 2014

Is there a one "right" PES statement??

Dietitians are concerned about getting the PES statements "right" and are looking for an "answer" to a case that shows the perfect PES statement.

Frequently during NCP/IDNT workshops they are assured that usually there isn't a single "right" PES statement to describe the nutrition problem that they have identified.  And then the discussion goes on to elaborate on how various PES statements could be used to describe the dietitian's judgments about a patient/client's problem that they have chosen to address in their nutrition care.

In some cases, the attendees may interpret this to mean that "anything goes" when it comes to writing a PES statement...this couldn't be further from the truth.  The original point that was being made during the workshop was the importance of focusing on creating PES statements that were as descriptive as possible.  However, the underlying assumption is that the dietitian is competent and has indeed evaluated the nutrition assessment data appropriately and selected one or more appropriate nutrition problem(s) to address--and the focus of the workshop is to help that competent dietitian to best use the IDNT terms available to create one or more PES statements that describe their approach to the nutrition care.

This in no way means that dietitians, or dietetics students in particular, will always appropriately assess the nutrition assessment data and correctly identify a relevant or the most relevant nutrition problem(s) to address. Certainly if the dietitian or dietetics student has made an error in collecting the nutrition assessment data, has selected an inappropriate standard for comparison, or has not appropriately identified the most critical nutrition problem (in the context of the medical conditions and patients' preferences) this will lead to selection of an inappropriate nutrition diagnoses and therefore a PES statement that is "wrong".  

Assuming that the nutrition assessment has been properly completed, a set of questions/criteria have been developed to assist dietitians in creating documentation that best describes the nutrition problem/diagnoses that they have selected and demonstrates the logical thinking of the Nutrition Care Model.  These questions focus on evaluating each component of the PES statement to see if there are opportunities for improvement in constructing the PES statement.

First look at the Nutrition Diagnosis term (Problem) that has been selected and answer the following questions:'
          – Can the dietitian resolve or improve the nutrition diagnosis?     
          – Consider the intake domain as the preferred problem     

Then, look at the wording that has been selected for the etiology and answer the following questions:

          - Is the etiology the “root” cause?     
          – Will dietitian intervention resolve the problem by addressing the etiology?     

           Note :If the dietitian intervention can not directly affect or resolve the stated etiology then can RD
                          intervention at least lessen the signs and symptoms?     

Next look at the Signs and Symptoms and answer the following questions:

          – Will measuring the signs and symptoms indicate if resolved or improved?     
          – Are the signs and symptoms specific enough?     

And finally look at the overall PES statement and ask yourself:

          – Does nutrition assessment data support the nutrition diagnosis, etiology, and signs and symptoms?

Educators who are training dietetics students know that students can have a great deal of difficulty identifying the most relevant nutrition problems to address.  There are other teaching strategies to assist students in first identifying the most appropriate nutrition diagnoses, and then these questions may be useful to help them construct their PES statements.

However the ability to think critically in the nutrition assessment step is a topic unto itself and is definitely a separate critical skill to be developed and honed.  The November 2013 Academy practice paper authored by Pam Charney and Sarah Peterson discusses the critical thinking that is necessary during the nutrition assessment and diagnosis that will lead the dietetics student and dietitian to the appropriate nutrition diagnosis(es).

Bottom line:  Is there a "right" and "wrong" PES statement?  Certainly there are instances where a "wrong" problem/nutrition diagnosis is identified and this will obviously lead to a "wrong" PES statement.  However if we spend too much effort on creating the perfect PES statement we may miss the entire point of providing the right nutrition care.  Just as there is not a "right" nutrition progress note or a "wrong" nutrition progress note, there are some that are more clear and concise than others and better describe the patient care episode...the same is true for the construction of a PES statement.

Our energy is better spent on honing our nutrition assessment skills and diagnostic reasoning to identify the most appropriate nutrition problem and the most effective intervention to improve the nutrition problem than obsessing about getting the perfect PES statement!.

Links of Interest:

Academy Practice Paper- November 2013.  Critical Thinking in Nutrition Assessment and Diagnosis

Sunday, April 20, 2014

Nutrition Progress Notes: Form follows function

While the principle of "Form follows function" is widely used in architecture, it is equally applicable as we think about nutrition progress notes.  As we consider the optimal nutrition progress note format and content, it is important to think about the purpose of a nutrition progress note and the intended audiences.  While there may be slight differences in the target audiences between various practice settings, most can be grouped into the following target audiences
  • Healthcare Team Members (Physicians, Nurses, and Dietetics practitioners)
  • Accrediting Agencies, Regulatory bodies, and legal audiences
  • Patients (there is a growing trend to use the medical record as a communication tool with the patient)  
When we think about these target audiences we also think about what is important for each of them::
  • Continuity of care (from dietitian visit to dietitian visit, among physicians, nurse and other health care providers)
  • Description of and rationale for care (for legal purposes, so enable reviewers to make judgments about whether standards of care were met)
It is important that the nutrition progress note include a clear and concise description of exactly what care was provided, include the rationale or reason for the nutrition care provided or recommended, indicate the anticipated outcomes of care, and indicate the connection or relationship with other aspects of healthcare being provided, considered, or recommended.  The Nutrition Care Process is a logic based problem solving methodology and the IDNT is intended to provide the language that is precise, yet easily understood by the target audiences.

A set of questions was developed to evaluate the nutrition progress note to ensure that the logic of the NCP is captured in the written progress note  This work was originally published in 2005 by Nancy Hakel-Smith, Lewis and Eskidge and has since been adapted and posted on the Academy website in two versions...a simple version and version that can be "scored" to more clearly show improvement over time. The version that can be scored was adapted by Dee Pratt and Sherry Jones.   This questionnaire has also been adapted for international use in Sweden by Lovestam et al to evaluate and compare documentation of NCP in electronic patient records.  Scores from the 14 items used to evaluate the notes placed these notes into three different quality levels (high, medium and low).  These tools are valuable ways to check our documentation to ensure that our care is adequately described.  In some cases the areas for improvement are simply opportunities for clarity in documentation, in other instances this evaluation may highlight areas where the nutrition care itself may be improved.

We continually seek ways to improve our nutrition care and the documentation of the care to ensure that patients and clients receive the best possible care and have the highest possibility of achieving optimal health through nutrition.    

Links of interest

Hakel-Smith, Lewis and Eskridge. Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners.  JADA, 2005  PUBMED ID: 16183359

Academy Members Only Link to Brief Chart Audit Tool and Comprehensive Sample Chart Audit Tools:

 Lovestam, Orrevall, Koochek, Karlstrom, Anderson    Evaluation of Nutrition Care Process documentation in electronic patient records need improvement.  Scand J of Caring ScienceMay 2013 Abstract

Saturday, April 12, 2014

So what does the nutrition progress note look like?

Remember the old days with paper medical records??
Usually at the end of a workshop or training on the Nutrition Care Process (NCP) and International Dietetics and Nutrition Terminology (IDNT) the question may what does the nutrition progress note look like??  And the usual answer "it depends" on your charting system is accurate--- however entirely unsatisfying.

When we first rolled out the NCP and IDNT in the United States, we began thinking about using a documentation format that was tailored to the steps in the nutrition care process:  ADIME (just taking the first letters of each of the steps (A=Assessment, D=Diagnosis, I=Intervention, and ME=Monitoring and Evaluation).  We began testing it at the first two facilities (See link to article below).

We quickly found out that while this concept was appealing and worked well for the initial nutrition progress note, it was far from ideal when you tried to use the same ADIME format for the follow-up note.  The question arising when writing the follow-up note was "where do you put the results of the M&E planned in the first note?"  In the M&E section of the follow-up note?? Or somewhere at the beginning of the follow-up note, perhaps in the Assessment section?

Then the concept was shortened to ADI, which left the ME to be placed where it made the most the end of the first note (e.g.  ADIME) when the ME is used only to identify what will be evaluated in the future.  However the results of the ME indicators selected in the original progress note would logically be included in the first part of the "reassessment", now in the A portion of the ADI format for the followup note. However, this concept became very confusing about how to best explain the connection between A and M&E.  This situation
lead to including the words Assessment/Re-Assessment in the NCP model that was published in 2008 and clearer graphics were used in presentations describing the connection between M&E and Assessment in the NCP and IDNT.  After discussing this more and thinking about the impact of electronic health records, the Academy committees determined that creating a new format for nutrition progress notes might not be the most successful strategy.

Instead we focused our efforts on showing how the NCP and IDNT terms would be incorporated into the various charting formats.  Specifically focusing on working with electronic health records companies to identify formats for "click and pick" systems where the terms were automatically built into E H R templates.  Several leading companies in the US licensed the terms and one built out a template for dietetics for the at least two (diagnosis and intervention) steps of the NCP.  Another system identified placemarkers for where the nutrition components (e.g. nutrition diagnoses and nutrition interventions) would be placed into existing patient education components.  Work also began on creating a toolkit to help dietitians work effectively with their own institutional electronic health records staff and process.

In addition, several cases were developed and posted on the website demonstrating how the same patient information could be incorporated into several of the popular charting formats:  Narrative, SOAP, and ADI.  This was intended to show dietitians that the NCP and IDNT provided underlying principles, concepts and terminology that would be used regardless of the medical record documentation systems used.  In addition, toolkits were developed for specific patient populations that included cases and example medical record documentation.

The Bottom Line:  What does the note look like?  It will often be quite similar to ones that you write now--BUT.

  • will incorporate the logical thinking used to identify the nutrition diagnosis (using the IDNT terms for nutrition diagnosis) 
  • will include the components of one or more PES statement(s):   e.g., Problem (Diagnosis), related to Etiology (root cause for nutrition problem/diagnosis) as evidenced by S (signs and symptoms data from assessment that substantiates your selection of the nutrition diagnosis and etiology)  
  • your description of the intervention will use the terms from the IDNT intervention term list  
  • will likely have more clearly identified the indicators (from the IDNT Assessment/Monitor and Evaluation term list) that you intend to use for M&E to determine whether your current treatment plan/recommendations are effective
  • may be shorter, more concise, and show a clearly described rationale for your nutrition treatment plan or recommendation
It will NOT include the term numbers and designations from the IDNT (those are only in the background for computer programmers to use to ensure that the databases identify the term correctly).  
  • If you have electronic health records the codes will be the computer language that is used to link the terms together across your patient populations.  
  • If you are doing research the codes will allow everyone to see the definition of the data that you are collecting. 
  • If you are doing Quality Improvement, the codes will ensure that you are collecting data from the records using the definitions provided in the IDNT reference manual.  
Links to resource materials

Implementing Nutrition Diagnosis, Step Two in the Nutrition Care Process and Model: Challenges and Lessons Learned in Two Health Care Facilities  Pubmed ID 16183367

Monday, April 7, 2014

Is the "Clinical Impression" the same thing as the "Nutrition Diagnosis"?

After hearing the discussions at the recent Nordic Meeting for Dietitians about their use of the clinical impressions in daily practice, this raises the question of whether clinical impressions are the same as Nutrition Diagnosis?  

I can honestly say that I don't remember specifically learning about “clinical impressions” or hearing that term when I became a dietitian.  We were learning Nutrition Assessment, e.g. the different types of data to gather,  criteria to use to analyze the data before we recommended nutrition care and how to document using the SOAP format.  But I don't remember specifically discussing "clinical impressions".   And we all KNEW that only physicians could make a medical diagnosis (e.g. use the International Classification of Diseases).

Marion Hammond, Naomi Trostler and I are currently working on an article that describes the historical development of the Hammond Models describing clinical dietetics practice in the 1970 to 1989 at Pennsylvania State University.  In the Hammond Models from 1977 through 1986, there it is--clear as day!!  Under the Nutrition Assessment step the last activity is described as the clinicians’ subjective "impressions".

Other medical professionals use "clinical impression" in a variety of ways:
  •  Psychology may use the term to mean the judgment of clinicians (and patients) on the outcome of a therapy.  
  •  Patrick Negilan in the Critical Care Medicine Tutorials discuss the clinical impressions as a "state of the patient" declaration... a useful way of assessing the problems presented to you prior to your assessment, the new problems that you discovered, and whether these are resolving or not. 
  •  One VA posting indicates that “Impression is used by most practitioner's when completing the chart and used to formulate the plan of care. A definitive diagnosis is made when the impression has been confirmed by other diagnostic tests to include, labs, X-rays, mri's, biopsy etc”.
  •  Chiropractors refer to the clinical impression similar to the discussion by the VA, as the “working diagnosis” that must be used if there is an absence of a confirmed diagnosis. 
  •  Other sources seem to indicate that the “clinical impression” is the same as a “working diagnosis”

So then what is a diagnosis? 

The IDNT Reference Manual 2013, indicates that Nutrition Diagnosis is the identification and labeling of the specific nutrition problem that food and nutrition professionals are responsible for treating independently. 

However prior to the Academy acknowledging and promoting the concept of Nutrition Diagnosing, Dr Mary Ann Kight had pioneered work on nutrition diagnosing in the 1970's.  Sandrick shared some of Dr Kight’s perspectives in a 2002 Journal article called "Is Nutrition Diagnosing a critical step in the nutrition care process".  Dr Kight referenced medical literature from the 1960’s as guiding her development of the concept of nutrition diagnoses.  King described the three components that had to be present in a diagnosis: 
  1.   Pre-existing series of categories or classes with defining criteria that allowed for ruling in and ruling our placement into a category(ies)/class(es)
  2. The entity or object to be diagnosed
  3. A judgment that the object meets the criteria to be placed into a specific category/class versus a different category/class.

We can also look to other healthcare professions like nursing and physical therapy for their description of diagnoses within their profession.

A nursing diagnosis is defined as “a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” (Herdman, 2012, p. 515). 

Physical Therapy
“Diagnosis in physical therapy is the result of a process of clinical reasoning that results in the identification of existing or potential impairments, activity limitations, participation restrictions, environmental influences or abilities/disabilities.  The purpose of the diagnosis is to guide physical therapists in determining the prognosis and most appropriate intervention/treatment strategies for patients/clients and in sharing information with them.”

Bottom line:  Both terms involve the clinical judgments based on an analysis of gathered data about a patient/client’s condition and lead toward the next steps in providing healthcare for the patient/client.  However clinical impressions don’t always carry the formality that is attributed to a “diagnosis”.   To be a diagnosis, you need to have a list of apriori defined conditions with signs and symptoms that are used to determine whether the patient/client meets the criteria for one or more “diagnosis(es)”. 

Links to more information:

Nutrition Care Process SNAPshots.  Available at: Accessed April 7, 2014.

Sandrick,K .  Is nutritional diagnosing a critical step in the nutrition care process?   2002 Mar;102(3):427-31. PMID 11902381

Negilan, P.  Critical Care Medicine Tutorials. Available at:  Accessed April 5, 2014.

NANDA.  What is Nursing Diagnosis - And Why Should I Care?  Available at: Accessed April 6, 2014.

World Confederation for Physical Therapy, Policy statement: Description of physical therapy, Available at:  Accessed April 5, 2014.
Clinical Guidelines for Chiropractic Practice in Canada,  Chapter 7 - Clinical Impression and Diagnosis.  Available at:  Accessed April 5, 2014.

Difference between a Diagnosis and/or Impression.  Available at:  Accessed April 5, 2014.

What is in an "impression diagnosis"?  Available at  Accessed April 4, 2014.

Definition of diagnosis:  Available at:  Accessed  on April 6, 2014.

Definition of Medical Diagnosis:  Available at: Accessed April 6, 2014.

Thursday, April 3, 2014

Why even have a common NCP model??

Genesis of need for model

Recently the history of the development of the Hammond Models was compiled.  Marian identified that in the 1970"s the driving force for her work on creating a pictorial model was to make it easier to educate dietetics students.   The profession in the United States was transitioning from focusing on nutrition through provision of food to hospitalized patients (therapeutic dietitians) to an expanded role in nutrition counseling and outpatient services.  

Later in 1998 when the Academy began it's journey to develop a common model, the activity was driven by the need to be able to clearly show the relationship between the actions of dietitians (nutrition care) and their patient outcomes.  In order to research and document the link between dietitians activities and patient clinical outcomes a common model and terminology was needed.     

Benefits of having common model

As dietetics is increasingly becoming a global profession with both dietitians and patients transitioning country borders, it makes it increasingly more important for dietitians to practice in a similar way and achieve similar patient outcomes.  The following are considered the benefits of having a global dietetics practice model:
  • Sets the stage for the development of global educational standards
  • Sets the stage for development of global credentialing requirements
  • Common educational and credentialing requirements lead to trans-global practice
  • Sets the stage for common dietetics outcome research projects 

Wednesday, April 2, 2014

Welcome to Nutrition Care Process Blog

This blog is devoted to answering questions and sharing perspectives on the Nutrition Care Process (NCP) and the standardized language. 

Even though the NCP Model published in 2008 in the Journal of the Academy of Nutrition and Dietetics was developed by members of the Academy of Nutrition and Dietetics, input was received from international dietetics professionals at various points in the process.  Each time NCP workshops and presentations were provided to international audiences questions and comments were brought back to the committee for consideration in the next revisions.  Formal input was solicited during two international meetings in 2005 and 2010.  More recently international representatives are included in the international panel and participate in ongoing dialogues about the terminology as well as the NCP Model.

Questions still arise about how closely this model reflects practice in dietetics in other countries.  However a number of dietetics organizations outside the US have evaluated the NCP model and determined that it was either acceptable as published or with minor modifications it would represent practice in their country.  This blog will present the following types of topics and welcomes your input for discussion:

     -Applicability of Nutrition Care Process to various practice settings
     -Specific applications of each component of the NCP Model
     -Use of the International Nutrition and Dietetics Terminology
     -Application of NCP and IDNT in electronic health records

Links to Nutrition Care Process Related Material