Nutrition Care

What is the nutrition care process (NCP)? How does it effect how I document information? Can I still include all of the things that I do as a dietitian? These are all questions that have arisen since the American Dietitian Association (ADA) issued the recommendation to transition to NCP from the traditional SOAP note.

According to the ADA: “The NCP is a systematic approach to providing high quality nutrition care. It was published as part of the Nutrition Care Model. Use of the NCP does not mean that all patients get the same care. Use of a care process provides a framework for the RD to individualize care, taking into account the patient’s needs and values, and using the best evidence available, to make decisions. Other disciplines in healthcare, including nurses, physical therapists and occupational therapists have adopted care processes specific to their discipline. In 2003, the House of Delegates (HOD) of the American Dietetic Association (ADA) adopted the NCP in an effort to provide dietetics professionals with a framework for critical thinking and decision-making. Use of the NCP can lead to more efficient and effective care and greater recognition of the role of dietetic professionals in all care settings.” www.eatright.org (accessed 09/2007).

What we do to provide patient care has not changed. The NCP provides a framework and dialogue that allows us to present our activities so that other members of the treatment team can understand our decisions and the rationale for these decisions. This gives added validity to our work.

GMDI wants to help make this transition smoother for the dietitians that follow individuals with genetic metabolic disorders. The Research Committee established a special subcommittee, co-chaired by Linda Tonyes and Lindsey Vaughn, to guide you through the NCP process. There will be a series of articles posted on the website and in the newsletter over the next year that we hope will answer your questions and allow dialog among members about application of the NCP to genetic metabolic patients.

Lindsay Vaughn volunteered to co-chair this subcommittee because, as she explains:
“I learned how to use the nutrition care process while working on my degree. As an undergraduate, I started with SOAP notes and by the time I graduated we were in the first stages of implementing the NCP. My internship preceptor had no idea why I was charting the way I did, and would make me redo all of my notes because ‘dietitians aren’t supposed to diagnose anything’. By the time I completed my MS degree, we all were comfortable using the NCP. I currently use it everyday and it has become second nature to me. I hope that I can help make the transition easier for those that are still very new to the process, since I have documented using both SOAP alone and with the NCP process.”

Frequently Asked Questions:

1. The Nutrition Care Process (NCP) appears to be solely problem-oriented, with the Assessment recording all problems (or data) on history, anthropometry, and biochemistry to arrive at a diagnosis. Is there a place for positive statements that show improvement, items not needing intervention, or historic information that is important for communication with other clinicians?

You can capture improvements indirectly within the Nutrition Assessment and Re-assessment steps of the NCP.
Example: Pt. reports dietary PHE is tracked on 3/7 days when previously never tracked;or, 50% of PHE levels are 2-6 mg/dl when previously 0% were 2-3 mg/dl.
Positive changes in patient progress can also be included in the Intervention step of NCP.
Example: Pt. continues to address weight. Pt. has reached half-way mark in achieving goal of 52 kg.
Additionally, some practitioners include an addendum to their notes titled, Other Nutrition Issues, where information can be included when there is no other logical place for it.

2. Patients with IEM typically have many needs including educational, self-management skills, economic, etc. This may lead to many PES statements and nutritional diagnoses. What would be considered a typical number of diagnoses for these patients? Should there be a primary diagnosis, with several secondary diagnoses?

There is no typical number of diagnoses/PES statements. You need only one diagnosis/PES statement per session to write your note, however you have the choice to write more. Your time and the complexity of your patient will be factors in determining how many diagnoses/PES statements are chosen. The goal of NCP is to create concise documentation that pinpoints an exact nutritional problem that has been addressed in one session. All problems cannot be fixed in a single session.

Example: Identified PES for a 14 year old male with PKU.

• Guidance needed to select school lunches
• Dinner prepared in absence of single working mom
• Inadequate income for the purchase of low protein foods
• BMI > 97%
• Most recent PHE = 11.4 mg/dl
• Consumption of inappropriate high PHE foods
• Incomplete consumption of medical food

If the other 6 problems were not addressed in the nutrition session, those problems do not need to be part of the note. It is also possible to combine one or more problems if a single action addresses more than one problem.

3. Code NC2.1, “impaired nutrient utilization”, seems to adequately describe patients with IEM. Could this code be used for all patients without the need for any other codes?

Although this code did not originate with IEM patients in mind, it is an appropriate code to use. It is likely that there are additional nutritional diagnoses that need addressing.

4. Keeping in mind that the eventual goal is to receive reimbursement for nutrition services, would several nutrition diagnoses be better than one?

More nutritional diagnoses would not translate into more reimbursement. It is a tool to show what we are doing, as dietitians, so others can understand our plan. If we are only going to address one issue during that session, then write only one diagnosis.

5. Is it going to matter if we keep using the same problem for the same patient?

No. Especially in the case of inborn errors of metabolism, the underlying medical diagnosis that leads to so many nutritional problems will never go away. The same is true for non-IEM patients. If you are continuing with the same issue, use the same diagnosis to show that you are still working on it.

6. The nutrition diagnoses in the behavioral domain sound rather negative. Wouldn't our patients or parents get upset if they read of these "deficits" in the clinic note?

This is the standardized language of dietetics which is mirrored in the standardized language of other professions, such as in nursing, see:  http://www.sabacare.com/Framework/NursingProcess.html  Click on the tables for diagnosis and you will find “Knowledge Deficit”. This is a term that we have not used in the past, but it is a term that is well-understood by third party reimbursers.

If we send notes to the family, some could be offended by the language. At least one practice has changed the wording from, “nutrition related knowledge deficit” to “nutrition related learning needs”, for that reason. However, at this time this is not an official term.

7. How will a nutrition note be organized using the new nutrition care process?

It does not change the note. This is a tool to use in conjunction with the SOAP, ADIME, or narrative format. The terms have been re-named, but there is still a subjective section and an objective section. The big difference is the Assessment/Plan. The Assessment becomes the PES statement. The PES statement assesses all information from the subjective and objective areas into a concise thought. The Plan becomes the intervention (same thing, new word). There is also a section at the end for monitoring outcomes. This is a good way to show outcomes and progress from one session to the next. To view a side-by-side comparison of all three styles, go to www.eatright.org under Nutrition Care Process. Click practitioner, and then click case studies.

8. I feel like most of the time I do a great deal of case management. How will a nutrition note, written following the new nutrition care process, capture all of that important information?

You can still include all of the information using the NCP. But using the NCP forces one to include a statement, saying:
“This is what’s going on with the patient and this is what we’re doing about it”
As stated in other answers, it is still possible to include details that allow the note to communicate pertinent information about the patient to other health care providers.