Anticipatory guidance...Identifying nutrition problems that don't yet exist??

A key concept in the Nutrition Care Process is that dietitians identify an existing nutrition problem, called a nutrition diagnosis, by clustering existing signs and symptoms from the nutrition assessment that shows that the nutrition diagnoses exists.  So doesn't that eliminate the possibility of prevention and anticipatory guidance??


Nutrition Diagnoses/Problems
In 2011 (Third Edition International Dietetics & Nutrition Terminology) the nutrition diagnostic terminology was expanded to identify four nutrition diagnoses that provide the ability to "predict" future nutrition problems, thus supporting the concept of prevention and anticipatory guidance.

• Predicted inadequate energy intake (NI-1.4)
• Predicted excessive energy intake (NI-1.5)
• Predicted inadequate nutrient intake  (NI-5.11.1)
• Predicted excessive nutrient intake  (NI-5.11.2)
• Predicted food-medication interaction (NC-2.4)
• Predicted breast-feeding difficulty (NC-1.5)

The definition of these terms indicate that they are used to reflect future problems, e.g. intake of one or more nutrients that is anticipated  (predicted based on observation, experience, or scientific reason) to fall short of or exceed estimated nutrient requirements, established reference standards, or recommendations based on physiological needs.  

Etiology
The types of etiologies that would be the "cause" of these nutrition diagnoses could be scheduled or planned medical therapy or medication that is predicted (based on research, experience or scientific reason) to either increase or decrease nutrient requirements, or change the ability to consume, absorb, or utilize nutrients.  In some cases cultural or religious practices could also be the "cause" of predicted problems.   In other cases etiology may be social issues such as housing or living conditions or potential for environmental emergency or catastrophe/disaster shown through research to be risk factors for intake problems.  

Signs and Symptoms
But what about the need to have signs and symptoms to document the presence of the nutrition diagnosis?  In the case of "predicted" nutrition diagnoses the reference sheets  indicate that you may use "estimated" needs or "estimates" of future intake.  

 The data used for these estimates may be findings of research projects as opposed to actual patient data.  History or presence of a condition for which research shows an increased prevalence of insufficient nutrient(s) intake in a similar population may be used as a sign and symptom.  For example the post surgery predicted energy needs for someone that is scheduled to undergo major surgery for cancer may be based on research findings related to the energy needed for future wound healing combined with research that documents a simultaneous decrease in intake could document a predicted gap between future intake and requirements.   This would then be used to set the stage for anticipatory guidance prior to surgery about coping with the future situation.

PES Statements might be:
Predicted excessive energy intake related to future immobilization of leg and lack of awareness of changes needed as evidenced current PAL of 1.8 expected to go to 1.2 and estimated current intake of 2800 kcal compared to reduced energy requirements of 1800 kcal during restricted mobilization scheduled for 4 weeks in December.
    ( intervention might be nutrition education on energy balance and meal planning for lower energy intake.)

Predicted suboptimal energy intake related to scheduled head and neck radiation therapy, lack of awareness of future dietary requirements, and anticipated changes in appetite as evidenced by scheduled radiation for next 3 months and usual weight loss of 5-10 KG/month for other patients receiving similar treatment (reference as appropriate).
    ( Intervention might be nutrition education on principles.) 

Predicted excessive carbohydrate intake  or Excessive carbohydrate intake related to strong family history of diabetes and lack of perceived susceptibility as evidenced by reports of all siblings and parents with Type 2 DM and current carbohydrate intake inconsistent with principles of diet for prevention of Type 2 DM.
     (Intervention might be nutrition counseling using health belief model and education on principles of prevention of DM EBNPG recommendations.)

Predicted excessive intake of nutrients in foods not tolerated related to potential diagnosis of food intolerances/allergies as evidenced by history of gastrointestinal distress and pain.
    ( Intervention might be nutrition education and use of self monitoring to test tolerance of foods.)

Full descriptions of the "predicted" nutrition diagnoses are available in the electronic NCPT.  Available at:  https://ncpt.webauthor.com/.  

Is that all there is??? Getting beyond knowledge deficit diagnoses for IBD.

What about conditions where the focus of the nutrition care is to help the patient learn to identify foods that are tolerated so future dietary intake can be planned to avoid them, but still be nutritionally adequate??

One of the conditions that would likely lead to this type of nutrition care may be Inflammatory Bowel Diseases (IBD).  In this case the focus of the dietitian's care is often to guide the patient in effectively use self-management skills.  They may need to have a systematic way to monitor their dietary intake, identify signs and symptoms as they begin to emerge and more effectively identify what dietary components are likely to be connected to the GI disturbances.  The self-management skills would also include helping the patient identify when they need to seek medical/dietetics follow-up care vs when they can/should manage the issue themselves.

Depending on the focus of the dietitian's intervention nutrition diagnoses could range from:

Concerns over Knowledge

• Food and Nutrition-Related Knowledge Deficit - most appropriate when the patient is newly diagnosed or when patient acknowledges lack of knowledge about the principles and food tolerances.  

This type of nutrition diagnosis is easiest to document, justify and support with nutrition assessment data (statement from patient about desire to know more, or documentation that patient could not accurately respond to questions) and will easily lead to an intervention of nutrition education.  The nutrition education intervention can focus on principles of planning intake during times of remission (content) as well as how to identify "flare" and how to adjust dietary intake during those periods (application).  The education can also identify the content of "when should the patient seek additional health care vs when can they manage the situation themselves" (application)

However the experienced dietitian may not be satisfied with this level of sophistication and wish to more clearly describe their nutrition care.  Other types of nutrition diagnoses can be added that are likely appropriate to more fully describe the range of nutrition problems (diagnoses) that are being addressed and a more full range of interventions used by the dietitian.  Following are the types of issues that are likely to be encountered:

Concerns over intake issues:
These issues could be ones that already exist or predicted for the future.  Often there are intake issues likely to be of concern, for example energy, fat soluble vitamins, B12, soluble vs insoluble fiber, and Calcium.  

These could be identified either as existing problems (intake that is already compromised) or those that are likely to be compromised in the future with repeated flares or by elimination of foods that have been identified as not being well tolerated.

• Predicted suboptimal* energy intake - if they are concerned about a future problem that could result from a combination of reduced intake due to trying to avoid food caused GI disturbances combined with decreased absorption which could be supported by research/experience with other patients with similar IBD diagnoses and symptoms.
• Predicted suboptimal* nutrient intake - if the concern is about a specific nutrient or nutrients that are likely to be unavailable due to malabsorption, perhaps fat soluble vitamins which could be supported by research/experience with other patients experiencing compromised intake or absorption.
• Predicted excessive intake may be used if the concern if over nutrients in foods not tolerated related to potential diagnosis of food intolerances/allergies which could be supported with nutrition assessment data about their history of gastrointestinal distress and pain.

Concerns over other behavioral/environmental issues
In most cases the individuals with IBD also are coping with behavioral and attitudinal issues.  For example they may not be keeping adequate food journals to identify which food items are trigger foods for flares. They may also be denying that they have a chronic condition that will need long term management on their part.  These types of nutrition diagnoses will often lead to more nutrition counseling types of intervention in addition to the knowledge needed.  Following are some of the types of other nutrition diagnoses likely to be addressed:

• Self-monitoring deficit related to need to rule in and rule out specific food as evidenced by history of GI disturbances, medical diagnosis of inflammatory bowel, and unverified or changing food tolerances
• Unsupported beliefs/attitudes about food and nutrition-related topics -  related to not ready for lifestyle change and denial of impact of diagnosis as evidenced by expression of reluctance to implement self-monitoring or other lifestyle changes necessary to manage the IBD.
• Inability to manage self-care  related to newly diagnosed IBD and lack of previous exposure to information about IBD nutrition care as evidenced by new medical diagnoses in medical record and referral for initial evaluation for nutrition therapy for IBD.  This may be an appropriate nutrition diagnoses if the dietitian is focusing on helping the patient learn the principles as well as developing the skills to apply the principles in self-management.  This would also include helping the patient identify when they need to seek medical assistance and when they can manage on their own.  
• Not Ready For Diet/Lifestyle Change related to unsupported beliefs/attitudes about whether the IBD will resolve without lifestyle changes as evidenced by patient's ability to verbalize knowledge, but providing reasons why changes in lifestyle are not necessary/possible at this time.  This would be used when the patient is experiencing a conflict between "knowing" what to do and actually planning and making the lifestyle changes necessary to manage their condition

Concerns over GI tract functioning

In some cases the dietitian may want to focus on the GI malfunctioning.  However this may or may not be useful to effectively direct the nutrition intervention chosen.  If this option is chosen, the dietitian may choose:

• Altered GI function related to unspecified food tolerances as evidenced by flares of GI symptoms (diarrhea, bloating) and patient verbalizing not knowing which foods precede flares.

Concerns over food/medication interactions

In many cases patients are managed by medications that also have nutritional implications for increased appetite, decreased absorption of fat soluble nutrients, or bone demineralization.  In these cases, the dietitian may also want to address either existing or predicted food/medication interactions.  

• Food-Medication Interaction or Predicted food-medication interactions would be appropriate diagnoses to use in these situations  

Specific nutrition diagnoses reference sheets are available to help the dietitian decide which best describes their thinking about the types of nutrition issues they have chosen to address.

BOTTOM LINE:  Dietitians have many choices of nutrition diagnoses that can be used to  fully describe the focus and nature of the nutrition care provided.  Some are based on existing situations and some based on predicting future situations that are likely to emerge.

Academy of Nutrition and Dietetics, E Nutrition Care Process and Terminology (ENCPT) available at:   https://ncpt.webauthor.com/pubs/idnt-en/file.cfm?item_type=xm_file&id=88978.  Accessed December 26, 2015

*If a synonym for the term “inadequate” is helpful or needed, an approved alternate is the word “suboptimal.”

Should standardized language be used to write a nutrition diagnosis?

For most diagnoses all that is needed is an ounce of knowledge, an ounce of intelligence, and a pound of thoroughness. 

— Anonymous

Arabic Proverb. In Lancet (1951). In John Murtagh, General Practice (1998), 125. 

One question that was raised during the MEDNA pilot survey last year was "Should standardized language be used to write a nutrition diagnosis?"

You really can't make a nutrition diagnosis UNLESS you have a standardized language.  In order to make a diagnosis of any kind, you must first have a list of diagnosis with descriptions that can be used to select/assign a nutrition diagnosis.  

To explain this thinking, here is a bit of background on the definition and description of "diagnosis".    

In  the Journal of the American Medical Association, in 1967 LS King, MD, discussed three critical components that needed to be present for the diagnosis process:  
     1-A preexisting series of categories or classes to provide the framework for the diagnosis
     2-A particular entity/situation that is being evaluated (patient's situation)
     3-The deliberate judgement that the entity being evaluated belongs to THIS particular category (versus other categories)

In this article King referenced an older reference, The Principles of Sciences:  A Treatise in Logic and Scientific Method  by Jevons, WS that was originally published in the 1830's and again in 1913.  It described diagnosis as follows:   

 " Diagnosis consists in comparing the qualities of a certain object with the definition of a series of classes;  the absence in the object of any one quality stated in the definition excludes it from the class thus defined;  whereas, if we fine every point of a definition exactly fulfilled in the specimen, we may at once assign to the class in question."  

Webster dictionary states that the first known use of the word diagnosis was in 1655 and it's language origin is from the Greek words,  diagignōskein meaning to distinguish and gignōskein meaning to know (Miriam Webster Dictionary)

So Bottom line:  You need to have a list of categories of nutrition diagnoses and corresponding descriptions that will allow the dietitian to accurately determine whether the patient's signs and symptoms match a preexisting definition of a particular nutrition diagnosis.

References:

King, LS.  What is a Diagnosis?  Journal of American Medical Association.  1967;202(8):154-157.

Jevons, W S. The Principles of Sciences:  A Treatise in Logic and Scientific Method. Second ed.  London, Macmillan and Company, Ltd., 1913.

Current definitions of "Diagnosis" in dictionaries follow:

• The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.(The Free Dictionary)
• The process of determining by examination the nature and circumstances of a diseased condition. (Dictionary.com)
• The identification of the nature of an illness or other problem by examination of the symptoms: (Oxford Dictionary)

Comparative Standards...why are they part of nutrition assessment?

The Nutrition Assessment Terminology includes a domain called Comparative Standards as an additional resource.  To understand why they are included we can go back to the description of nutrition assessment itself.
The Nutrition Assessment Component Summary identifies the following three activities in Nutrition Assessment:

• Reviewing data collected for the purpose of identifying factors that influence nutritional status or health status
• Clustering the data collected to identify a nutrition diagnosis (using the signs and symptoms on the nutrition diagnosis reference sheets as a guide)
• Identifying which standard will be used to compare the data against to determine if it is "unusual", for example either higher than expected or lower than expected.

One type of critical thinking that takes place during the Nutrition Assessment step is to identify what standards should be used to compare the data against, e.g. what is the appropriate comparative standard. How much energy is too much?  to little?  How much Vitamin B6 is too much or too little for this patient?

To assist the dietitian in explaining the care that is being provided we have Comparative Standards.  The E-NCPT includes a sixth domain as an addendum to the Nutrition Assessment terminology that is to be used to document how the dietitian "evaluated" the data collected from the patient or medical record during the nutrition assessment data collection.  These terms allow the dietitian to enter data into fields in the following categories:

Class/Category	Each allows the dietitian to identify both the estimated need as well as method to measure of estimate the need/requirement
Energy Needs	Kcal Specify formula and activity/injury factors used
Macronutrient Needs	Daily intake in grams of fat, protein, carbohydrate (type and total quantity), or fiber Method of estimating (for example if national reference standards are used such as Dietary Reference Intakes or disease related standards)
Fluid Needs	Fluid Method of estimating
Micronutrient Needs	Vitamins (A, C, D, E, K, Thiamin, Riboflavin, Niacin, Folate, B6, B12, Pantothenic acid, Biotin) Minerals (Calcium, Chloride, Chromium, Cobalt, Copper, Fluoride, iodine, Iron, Magnesium, Manganese, Molybdenum, Phosphorus, Potassium, Selenium, Sodium Sulfate, Zinc) Method of estimating needs
Weight and Growth Recommendations	Ideal body weight parameters, BMI, or growth patterns for children (weight for age, length of age, head circumference or weight for stature, or BMI for age)

In addition the Comparative Standards includes additional reference material that addresses concerns that dietitians may have when using national reference standards that were developed for groups of "healthy" people and then applying these standards to individuals who may not be "healthy".

 While the E-NCPT includes the Dietary Reference Intakes (DRI) used in the United States and Canada, it also addresses using other country's national reference standard when they are available.

If you have access/subscription to the E-NCPT the following pages address the information summarized in this blog.

Nutrition Assessment Component Summary in ENCPT

Nutrition Assessment - Identify relevant data by comparing to standards in ENCPT

Guidance for interpreting national reference standards - both US and Internationally in ENCPT

Roadmap for Implementing NCP

"Good ideas are not adopted automatically. They must be driven into practice with courageous impatience. Once implemented they can be easily overturned or subverted through apathy or lack of follow-up, so a continuous effort is required.“
-- Admiral Hyman Rickover (1900-1986)
The Academy of Nutrition and Dietetics Nutrition Care Process and Standardized Language Committee reviewed change management literature from 2003 to 2008.  One reference used was the book Leading Change.  John Kotter of Harvard Business School published steps in implementing organizational change that have been used to guide teams of dietitians as they implemented the Nutrition Care Process and standardized language.  Kotter's eight stage process can easily apply to teams of dietitians implementing the nutrition care process in medical organizations.

Kotter's Eight Stage Process used to lead successful change is:

1-Establishing a Sense of Urgency

Examine the circumstances leading to the decisions to implement, identify and discuss crises, potential problems or major opportunities

2-Creating the Guiding Coalition

Put together a group with enough power to lead the change and get the group to work together as a team

3-Developing and Vision and Strategy

Create a vision to help direct the change effort and developing strategies for achieving that vision

4-Communicating the Change Vision

Use every way possible to communicate the new vision and strategies and have the leadership demonstrate the behavior expected of others in the organization,  

5-Empowering Employees for Broad-Based Actions

Eliminate obstacles, change structure or systems that undermine the vision and encourage risk taking, nontraditional ideas, activities and actions.  

6-Generating Short-Term Wins

Plan for visible improvements in performance, create those wins and visibly recognize and reward people who make the wins possible.

7-Consolidating Gains and Producing More Change

Use newly developed successful processes/products to change all systems, structures, and policies to be consistent with new vision.  Develop the capacity of people who CAN implement the vision and re-imagine the process with new projects, themes, and change agents.

8-Anchoring New Approaches in the Culture

Create better performance through focused, leadership, management; articulate the connections between the new behaviors and organizational successes, ensure leadership development and succession.

Read more examples of implementation through published journal articles.  For example, the Journal of the Academy of Nutrition and Dietetics has special feature called "collections".  One of the collections that have been gathered is a group of articles published on the Nutrition Care Process and standardized language.  If you log on to the Journal page, the "collections" tab is the second tab on the navigation bar.  You will find several articles that summarize various methods use to implement the NCP and standardized language.  

Kotter, J.P.  Leading Change, Harvard School Press 1996

Journal of Academy of Nutrition and Dietetics

Seems like the NCP and IDNT is for the dietitian....not the patient??

For Dietitian??  or  For Patient??  or BOTH??   It would seem that the process is for both.  While it is true that the dietitian is the professional that "uses" the process to provide high quality services, the patient really receives the benefit.

The model clearly recognizes the need to put the patient in the CENTER of  the dietitian's activities as shown in the model.  While the model describes the activities from the dietitians viewpoint, the words used are intended to describe a COLLABORATIVE process.

The words used in the 2008 NCPM article describing this are:  " The central core of the model depicts the essential and collaborative partnership with a patient/client. The model is intended to reflect the dynamic nature of relationships throughout the NCPM."

In the chapter/text describing the intervention the following is included: " It is most desirable to set goals jointly with the patient/client".

The Nutrition Counseling intervention is described as "a supportive process, characterized by a collaborative relationship between the counselor and the patient/client to establish food, nutrition and physical activity priorities, goals, and action plans that acknowledge and foster responsibility for self-care to treat an existing condition and promote health."

The IDNT or NCPT (Nutrition Care Process Terminology) is designed to concisely describe the elements and results of each step in the care process using terms familiar to healthcare professionals, not necessarily patients.  The goal of the terminology as stated in the 2008 article on the terminology is to  "provide a standardized set of terms used to describe the results of each step of the model".  The initial list of standardized terms was developed in the United States and heavily reflects the common healthcare language at the time of development.  The cultural and language differences are acknowledged during the "translation" process for the standardized language into other languages, e.g Swedish, French, or Norwegian.  The persons completing the translation have found situations when there are no comparable words that correspond directly to the meaning of the US term or when terms are used differently in different cultures.

The new webpage NCP 101 includes additional information and links to materials that may be helpful.

Link to 2008 NCPM Article
Link to 2008 IDNT  (terminology) Article
Link to NCP 101 webpage

Can NCP be implemented without government or organizations enforcing implementation?

"You've convinced me. Now go out and make me do it."  This statement was made by Franklin D Roosevelt, 32nd President of the United States (1933-1945) when he met with supporters and asked for their grassroots support for his government programs.  
Perhaps this quote applies to one of the questions posed by participants in the MEDNA survey which was about the need for "enforcement" in order to successfully implementation of the Nutrition Care Process and standardized terminology.  

The NCP Model diagram clearly acknowledges the importance of the healthcare environment as it impacts the NCP ( it is specified in an outer ring).  Certainly support from government ministries, agencies that regulate healthcare, and professional organizations is highly desirable and will greatly facilitate the speed with which the NCP implementation and use of the standardized terminology can occur. Dietitians must be knowledgeable of their healthcare environment to determine how to best approach the implementation so that it is consistent with existing regulations in their healthcare systems.  

But since the NCP is the thinking process that the dietitian uses as they provide care, this aspect of our profession practice is rarely completely controlled or enforced by a governmental agency or professional association.  The same is true of the words (standardized terminology) that is used in our documentation in the medical record to describe the nutrition care that we provided.  Governmental agencies and professional societies/organizations often do not have the authority or desire to control a practicing dietitian at this level of detail.  So while support is highly desirable, it is not likely that "enforcement" is required prior to starting implementation of  the NCP and standardized terminology.

For example in the United States, the Academy of Nutrition and Dietetics fully supports the NCP implementation, but  does not have any authority to actually "enforce" the actual implementation in daily practice.  Position papers, practice papers, books, publications, and evidence based guidelines provided by the Academy to assist dietitians in practice now reflect the Nutrition Care Process.  The Commission of Dietetics Registration includes it in the national registration examination along with the other topics.  ASCEND, the accrediting body for dietetics education programs, also includes it in the standards of education, but seeking accreditation is technically a voluntary process.  The incorporation of the NCP into these processes and documents has taken a decade.

In the United States, the use of the NCP and standardized terminology are not in conflict with governmental regulations or other healthcare standards.  In fact, the use of the NCP is helpful in meeting accreditation standards by The Joint Commission that require that a standard approach to nutrition care be followed.  

The Clinical Dietetics manager typically would have a key leadership role in directing the dialogue about how the NCP and standardized terminology should be used in their facility. However we have found that dietitians at all levels in the organization have taken the lead in learning about the NCP,   bringing up the topic,  educating others on the topic,  and being the ones that "experiment" with implementation.  One of our first implementation sites in the United States was started by a dietetic intern who was assigned to provide an "inservice" to the dietetics staff on the new concept of nutrition diagnosis.  Her inservice project provided the impetus for implementation and eventually the publication of the article that described their implementation process. (See article listed below)

In the end, it is up to the healthcare organization that actually hires and directs the work of the dietitian to set the job performance standards and "ensure" that the NCP and standardized terminology are implemented.  The hospital or healthcare organization develops the position descriptions, determines if they will audit the records for completeness and accuracy of nutrition care, and establishes the scope of practice for the dietitian in their organization.  

Bottom line:   the healthcare organization that employs the dietitian usually has the most influence on the actual implementation process.  

Mathieu, J, Foust, M, Oullette, Implementing Nutrition Diagnosis, Step Two in the Nutrition Care Process and Model: Challenges and Lessons Learned in Two Health Care Facilities.  J of Am Diet Assoc 105(10):  2005.  P 1636-1640  http://dx.doi.org/10.1016/j.jada.2005.07.015

“We are stuck with technology when what we really want is just stuff that works.” NCP & EHRs

“We are stuck with technology when what we really want is just stuff that works.”  quote from -- Douglas Adams, author of The Salmon of Doubt.
We have a love-hate relationship with technology...especially Electronic Health Records (EHR).  It would be nice if someone just came up with the perfect answer for how to incorporate NCP into an EHR.  But, there are almost as many ways to incorporate the Nutrition Care Process and terminology into the E H R as there are dietitians.  You can start incredibly simple or it may require extensive  programming by informatics specialists.  Your organization needs to determine what will best meet your needs.

On the simplest end of the continuum, a template can be developed with standard headings with "free text boxes" to prompt the dietitian as they write their progress note.  As shown below, the dietitian then simply types in the data and information just as he/she might write a note long-hand but uses the terminology as appropriate.  Sample headings shown below:

• Assessment/Re-Assessment
• Monitoring and Evaluation Data (Follow-up Note only)
• Nutrition Diagnosis
• Status of Previous Nutrition Diagnosis (Follow-up Note only)
• Nutrition Prescription
• Nutrition Intervention
• Plan for Monitoring and Evaluation

The purpose of this type of template would be to assist the dietitians in remembering to follow the process and document their care using the standardized terminology.  However it provides only extremely limited ability to capture data to use for reporting outcomes management or summarizing the type of nutrition care being provided in the institution.  It relies completely on the dietitian to remember and use the correct terms.  If you are able to recall reports, the "data files" will be the free text and someone will have to go through and create "countable data" from each file manually in order to summarize.  The types of things that might be useful would be the percent of patients where the Nutrition Diagnosis is improved or resolved, the frequency of nutrition diagnoses, frequency of nutrition interventions.  This is clearly not optimal and does not harness any of the benefits of the electronic health record!!

On the other end of the continuum would be the capability to program decision support prompts to help the dietitian enter patient care, similar to what the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) system does.  It automatically incorporates the data fields, data terms for Nutrition Diagnosis, Nutrition Intervention, and Monitoring and Evaluation.  And it "prompts" the dietitian with the most common etiologies, signs and symptoms and intervention to match the nutrition diagnosis/etiology.  This type of "smart" system will yield the most benefit in terms of saving time and allowing the users to create meaningful reports and analyze data to answer key questions about outcomes.   

The website contains a number of short videos that describe how the ANDHII works so a person can visualize the potential capabilities.  The best video to start with might be the overview of the Smart Visit.  When you see the demonstration of the Nutrition Diagnosis you will see that ANDHII automatically pre-populates suggestions for etiologies and signs and symptoms. 

The solution for your organization is likely somewhere in between these two extremes.   If you need help learning about how to work with electronic health records a toolkit (one per institution) was created for dietitians is available in the Academy "shop".

Please share your experiences in incorporating both NCP and the terminology into electronic health records!!

References:

Murphy, W, Steiber, A.  A New Breed of Evidence and the Tools to Generate It: Introducing ANDHII

Journal of the Academy of Nutrition and Dietetics, 2014:115(1)p 19-22  

DOI: http://dx.doi.org/10.1016/j.jand.2014.10.025

Like Hand in Glove...The Evidence-Based Nutrition Practice Guidelines and NCP go together!!

The Evidence Based Practice Guidelines published on the Evidence Analysis Library are organized by the steps in the Nutrition Care Process.  The specific project on the EAL that discusses critical care is called the Critical Illness project.  

On the introductory page to the project the Executive Summary is available to the public.  The recommendations are organized into Nutrition Assessment, Nutrition Intervention, and Nutrition Monitoring and Evaluation.  

Recommendations that are included in the Nutrition Assessment section include the following topics:

• Assessment for Critically Ill Patient (identifies the types of data to be collected and evaluated)
• Reassessment of Critically Ill Adults (identifies the data commonly used in re-assessments)
• Resting Metabolic Rate Predictive Equations for Non-obese Critically Ill Adults
• Resting Metabolic Rate Predictive Equations for Obese Critically Ill Adults

Recommendations that are included in the Nutrition intervention section include the following topics:

• Nutrition Prescription for Critically Ill Adults (identifies what should be included)
• Enteral vs Parenteral Nutrition (includes when indicated and contra indicated)
• Use of Promotility Agent (identifies when they are recommended)
• Enteral Formulas Containing Immune-Modulating Nutrients in Patients without ARDS or Acute Lung Injury
• Enteral Formulas Containing Immune-Modulating Nutrients in Patients with ARDS or Acute Lung Injury
• Addition of Fiber to Enteral Nutrition to Reduce Diarrhea
• Supplemental Enteral Glutamine (summarizes research and identifies one potential target population)

Recommendations that are included in the Nutrition Monitoring and Evaluation Section are: 

• Monitoring and Evaluation of Critically Ill Adults (includes data  to be used)

If  you are a member of the Academy of Nutrition and Dietetics or if you subscribe to the Evidence Analysis Library, the systematic reviews and other supporting materials are also available.  

BOTTOM LINE:  The Nutrition Care Process steps are used to organize the recommendations for care in the Evidence Based Nutrition Practice Guidelines for Critically Ill Patients.  

Just do it!!! NCP and IDNT can be implemented without an electronic health record.

Dietitians who completed the MEDNA survey wanted to know if it was necessary to have an electronic health record before implementing the Nutrition Care Process.  Good news....there is no need to wait for implementation of an electronic health record to start using the Nutrition Care Process and standardized language.  They both can be implemented with or without electronic health records.

NUTRITION CARE PROCESS
Dietitians can use the nutrition care process to guide their thinking process and approach to nutrition care regardless of type of medical record being used. Often some (but not all) the activities outlined in the Nutrition Care Process are already being done by the dietitian.  The one step that may be missing in the past is the Nutrition Diagnosis step.  This is the step where dietitians formally define the nutrition problem(s) that they will be addressing.  The activity is summarized in a Problem-Etiology-Signs and Symptoms (PES) statement.

DOCUMENTATION
Healthcare institutions have policies and procedures that guide the type of documentation that dietitians can enter in the paper medical record as well as what section of the medical record the documentation is stored.   Documentation can be structured in a variety of formats.  Dietitians may find it easier to ensure that all the steps of the nutrition care process are documented if the documentation structure follows the nutrition care process.

Nutrition Care Process steps and standardized language can be incorporated into a variety of nutrition progress notes:  Narrative, Subjective-Objective-Assessment-Plan (SOAP), Subjective-Objective-Assessment-Intervention-Evaluation-Response (SOPIER) Problem-Intervention-Evaluation (PIE), Assessment-Diagnosis-Intervention (ADI) or,Assessment-Diagnosis-Intervention-Monitoring and Evaluation (ADIME). or FOCUS notes with separate data, action and response for each "focus".
Examples showing the information in Narrative, SOAP and ADIME formats are posted on the Academy website.  While some information is available to all, these examples are currently only available for Academy members.

Dietitians may also have separate templates for different types of documentation.  For example they may have a separate nutrition assessment form that collects all the data used in the nutrition assessment.  This form may be stored in a separate part of the medical record, just as the laboratory reports or radiological reports are stored separate from the medical progress notes.  See the previous blog about where the activities of each of the nutrition care process steps might be included in the various progress note formats: What Nutrition Progress Notes look like or Form follows function.  Toolkits are available for purchase that include examples of progress notes.

  But the biggest benefits occur when the standardized language is embedded in electronic health record software and the information entered in the progress note is collected as data that can be "counted" and reported.  When the terminology is embedded in an electronic health record, the E H R templates can prompt the dietitian for common data entries,  the data from the E H R can be summarized into reports and provide data for dietitians to use in evaluating the outcomes and characteristics of their nutrition care.  Multiple templates can be created with "smart" applications that assist dietitians as they provide care.

BOTTOM LINE:  You can start using NCP and standardized terminology any time, however the biggest benefits will occur when the electronic health records incorporate the terminology and process into documentation templates.