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*Certified in Canada.‡Certified in New Zealand.§Certified in Sweden.¶Certified in Australia.
2212-2672/Copyright ª 2019 by theAcademy of Nutrition and Dietetics.https://doi.org/10.1016/j.jand.2018.10.025
ª 2019 by the Academy of Nutrition and Dietetics.
FROM THE ACADEMY
Nutrition Care Process (NCP) Update Part 2:Developing and Using the NCP Terminology toDemonstrate Efficacy of Nutrition Care andRelated 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, RDNUTRITION AND DIETETICSpractitioners around theworld use the Nutrition CareProcess Terminology (NCPT)
to communicate the NutritionCare Process (NCP).1 In this article,nutrition and dietetics practitioners orprofessionals; dietitians; dietitians-nutritionists; and dietetic technicians,registered, are collectively referred toas professionals. The NCPT is a stan-dardized terminology or controlled vo-cabulary that complements the NCP, asystematic problem-solving roadmapfor planning and providing nutritionand dietetic care to individuals andpopulations, and researching relatedoutcomes. Recently, a scheduled up-date of the NCP and Model (NCPM)was published.2 The NCPM is thegraphic representation of the NCP. TheNCP includes four steps that collec-tively describe the unique contribu-tions of nutrition and dieteticspractitioners. These steps are NutritionAssessment and Reassessment, Nutri-tion Diagnosis, Nutrition Intervention,and Nutrition Monitoring and Evalua-tion. A companion to the model updatepublication, this article reviews thebackground of the NCP and describesthe current state and ongoing enhance-ments of the NCPT.2 A further aim is to
illustrate how the NCPT communicatesthe unique functions of nutrition anddietetics practitioners and supportsthe research on nutrition and dieteticscare. This article replaces previous in-formation on the use of the NCPT.
A DECADE OF USE ANDDEVELOPMENTThe NCPT, formerly known as the Inter-national Dietetics and Nutrition Termi-nology (IDNT), was designed to meet thedefinition of a controlled vocabulary asdetermined by the National Library ofMedicine.3 This means that the NCPT is asystem of terms organized in a hierar-chical structure, with definitions andcross-references used to index andretrieve a body of literature in a biblio-graphic, factual, or other database.4 TheNCPT was initially presented as a docu-mentation tool for electronic health re-cords (EHRs).5 Of note, the IDNT becamethe NCPT in 2014 to emphasize its link-age to the NCP. Today, the NCPT is a toolthat standardizes nutrition and dietetics-related communication beyond thehealth care setting and is capable ofdemonstrating quality of care and relatedoutcomes.In 2003, the Academy of Nutrition
and Dietetics (Academy), formerly theAmerican Dietetic Association,completed a review of defined healthcare vocabularies to evaluate whetherthese existing vocabularies adequatelycommunicated the scope of nutritioncare. Although several of the definedterms at the time included nutrition-focused terms, they did not describethe complete range or the specific ac-tivities performed by nutrition and di-etetics practitioners.6
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To address this gap in nutrition anddietetics terminology, the StandardizedLanguage Task Force, composed of 12Academy member volunteers supportedby terminology consultants and Academystaff, undertook development of termi-nology for the NCP step Nutrition Diag-nosis. Sixty-two Nutrition Diagnosisterms were published in 2006.7 Subse-quently, the Task Force developed termsfor the Nutrition Assessment, NutritionIntervention, and Nutrition Monitoringand Evaluation NCP steps. As a result, anofficial terminology that supported allfour steps of the NCP was published in2008.8 Currently, the NCP OutcomesResearch Committee (NCPROC) of theAcademy oversees the development andmaintenance of the NCPT with supportfrom its workgroups (ie, International,Advisory, and Classification) and incollaboration with the Council onResearch, Informatics, and Interopera-bility and Standards Committees. ThecompleteNCPT (electronicNCPT [eNCPT])is released once a year and is availablethrough a web-based platform.1 A book,the Abridged Nutrition Care Process Termi-nology (NCPT) Reference Manual: Stan-dardized Terminology for the Nutrition CareProcess9 provides a select subset of NCPterms in print form.
The NCPT has developed in severalaspects since its original launch. Severalinternational nutrition and dietetics or-ganizations work collaboratively withthe Academy to support, adopt, andtranslate the NCPT into different lan-guages (Figure 1).10-12 Also, the appli-cation and related experiences withNCPT have been reported in variouspractice and education settings.13-19 Tobetter communicate nutrition care inpractice and research, processes for
DEMY OF NUTRITION AND DIETETICS 1
Figure 1. International translations timeline. Countries that translated during the same year are listed in alphabetical order. *Country thathas conducted regular updates of the Nutrition Care Process Terminology. ND¼nutrition diagnosis. NI¼nutrition intervention.
FROM THE ACADEMY
modifying the NCPT have been imple-mented by the NCPROC that ensure aresponsive environment for NCPTenhancement. As a result, the numberof NCPT terms has expanded to supportthe range of skills and roles of nutritionand dietetics practitioners. Synonymshave been added that embrace practiceand cultural sensitivities. Because theNCPT is among many health care ter-minologies, its terms are submitted tolarger interdisciplinary internationalclinical terminology standards such asSystematized Nomenclature ofMedicine-Clinical Terms (SNOMED-CT)and Logical Observation IdentifiersNames and Codes (LOINC) on anongoing basis.20,21 In recent years, theNCPT has been used in practice-focusednutrition research showing the efficacyand degree of application of the NCP, aswell as adherence to evidence-basednutrition practice guidelines.18,22-24
NCPT: THE STANDARDIZEDTERMINOLOGY OF NUTRITIONAND DIETETICSThe NCPT is organized by NCP stepsand within each step it is organized by
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domains, classes, and subclasses(Figure 2). An extensive number of NCPterms have reference sheets that serveas a descriptive profile for the term.NCP terms on the reference sheets aredefined in the case that they do notexist in the international clinical ter-minology standards described else-where in this article.The purpose of the NCPT is to provide
an accurate and specific description ofthe services that nutrition and dieteticspractitioners deliver, and the investiga-tion of resulting outcomes. This achievesa common understanding not onlyamong nutrition and dietetics practi-tioners, but also outside the profession,including clients (individuals or pop-ulations) and other disciplines. Anothersubstantial purpose of the NCPT is that itprovides a means to show the influenceofnutrition careonoutcomesandqualityof care to health professionals and thepublic. Regardless of chosen note format(eg, the traditional Subjective, Objective,Assessment, Plan system or the Assess-ment, Diagnosis, Intervention, Moni-toring, Evaluation system) or othermeans of documentation/reportingbased on policy or personal preference,
N AND DIETETICS
nutrition and dietetics practitioners useNCPT to communicate care with preci-sion.23,25 Examples of the application ofNCP using NCPT in a variety of practicesettings are illustrated in Figure 3.
In a dynamically evolving health careenvironment, the vision for the NCP andNCPT is to facilitate communicationwithin and among health care systemsfor outcomes research and qualityimprovement. Thus, the NCPT is animportant tool to advance the field ofnutrition and dietetics, related educa-tion, research, and policy as the updatedlogic model guiding terminologydevelopment demonstrates (Figure 4).
Acceptance and AdoptionThe NCPT supports application of theNCP in numerous countries. The Euro-pean Federation of the Associations ofDietitians Report on Knowledge and Useof a Nutrition Care Process and Stan-dardized Language by Dietitians inEurope11 reported that there werepositive attitudes for the use of astandardized terminology that de-scribes the NCP. At the time of thissurvey, seven European countries
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NCP STEP DOMAIN HIGHLIGHT ON NEW TERMS
Detail Showing Malnutrition (undernutrition) TermsMalnutrition (undernutrition) (NC-4.1) Starvation related malnutrition NC-4.1.1Moderate starvation related malnutrition NC-4.1.1.1Severe starvation related malnutrition NC-4.1.1.2
Chronic disease or condition related malnutrition NC-4.1.2Moderate chronic disease or condition related malnutritionNC-4.1.2.1Severe chronic disease or condition related malnutritionNC-4.1.2.2
Acute disease or injury related malnutrition NC-4.1.3Moderate acute disease or injury related malnutritionNC-4.1.2.1Severe acute disease or injury related malnutritionNC-4.1.2.2
Non illness related pediatric malnutrition NC-4.1.4Mild non illness related pediatric malnutrition NC-4.1.4.1Moderate non illness related pediatric malnutrition NC-4.1.4.2Severe non illness related pediatric malnutrition NC-4.1.4.3
Illness related pediatric malnutrition NC-4.1.5Mild illness related pediatric malnutrition NC-4.1.5.1Moderate illness related pediatric malnutrition NC-4.1.5.2Severe illness related pediatric malnutrition NC-4.41.5.3
Detail Showing Popula�on Based Nutri�on Ac�on ClassesPopula�on Theore�cal Frameworks (P-1)
Popula�on Strategies (P-2)
Popula�on Se�ngs (P-3)
Popula�on Sectors (P-4)
Ass
essm
ent
and
Rea
sses
smen
t(1
,083
term
s)
Food and Nutrition-Related History (381 terms)
Anthropometric Measurements (88 terms)
Biochemical Data, Medical Tests, and Procedures
(228 terms)
Nutrition Focused Physical Findings (348 terms)
Client History (38 terms)
Dia
gnos
is (1
66 te
rms)
Intake (111 terms)
Clinical (38 terms)
Behavioral/ Environmental (17 terms)
Inte
rven
tion
(400
term
s)
Food and/or Nutrient Delivery (302 terms)
Nutrition Education (6 terms)
Nutrition Counseling(16 terms)
Coordination of Nutrition Care by a Nutrition
Professional (9 terms)
Population Based Nutrition Action (67 terms)
Mon
itorin
g an
d Ev
alua
tion
(1,0
45 te
rms) Food and Nutrition-Related
History (381)
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.
FROM THE ACADEMY
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CaseNCP
Public HealthSituation: Women ofreproductive age found withlow Hgba and iron-deficientdiet
FoodserviceSituation: In anatural disaster,it is estimatedthat 5 d areneeded to repairand restorepotable watersupply
Long-Term CareSituation: Daughter ofpersonal care home residentconcerned with mother’sfood intake. Resident hasswallowing difficulties
Acute CareSituation: Hospitalizedfemale teacher withcomplaint of undesiredweight gain. Reason foradmission: emergencyappendectomy
Nonacute CareSituation: Female teacher withcomplaint of undesired weightgain referred by hospital RDNb
(Same person as in Acute Care)
Assessment Food Intake: infrequentconsumption of iron-richfoods, Mineral element intake :<67% EARc for iron for genderand age,Nutritional anemia profile:Hgb: high incidence of valuesbelow the populationreference standard (40% ofwomen of reproductive age)Comparative standards:Estimated mineral needs: EARfor iron for women aged19-50 y¼8.1 mg/dHgb >120 g/L
Availability ofpotable water: a3-d supply of 1gal (4L)/person/d asrecommendedby EPAd isavailable
Food intake: Food consumptionreported to be <50% ofmeals. Reduced intakeprogresses throughout theday with fatigue andincreased signs/symptoms ofdysphagia.Weight loss: 7 lb (3.2 kg) inpast month (5% weight loss)Measured Weight: 148 lb (67kg)Nutrition-focused physicalfindings: Mild/moderate lossof muscle massDiet: Minced and moistComparative standards: Totalestimated energy needs in24 h: 1,500 kcal (6,300 kJ),Total estimated protein needsin 24 h: 80 g protein/dMethod for estimating totalenergy needs: 22 kcal/kg,1.2 g protein/kg
Energy intake: >2,200 kcal/d,(9,200 kJ/d) Age: 45 y Statedheight: 5 ft 5 in (163 cm),Stated weight: 190 lb (86 kg)Body mass index: 32.4, Obese.Meal snack pattern: Eatswhen not hungry. Types offood meals: High-fat foodsfrequently, Weight gain: 60 lb(27 kg) in 24 mo, Readiness tochange nutrition relatedbehavior: Contemplation,expresses concern abouthealth statusComparative standards: Totalestimated energy needs in24 h: 1,500 kcal (6,300 kJ),Method for estimating totalenergy needs: Mifflin-St Jeor
Weight Management RDNvalidates assessment datareceived from hospital RDNvia a Transition of Care(C-CDAe) document. (Inpractice this means that alldata from the acute caresetting (acute care case in thisFigure) were transmitted asdocumented to the nonacutecare setting.
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Figure 3. Terminology applications in a variety of practice settings. Nutrition Care Process Terminology terms are presented in boldface italic type.
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CaseNCP
Public HealthSituation: Women ofreproductive age found withlow Hgba and iron-deficientdiet
FoodserviceSituation: In anatural disaster,it is estimatedthat 5 d areneeded to repairand restorepotable watersupply
Long-Term CareSituation: Daughter ofpersonal care home residentconcerned with mother’sfood intake. Resident hasswallowing difficulties
Acute CareSituation: Hospitalizedfemale teacher withcomplaint of undesiredweight gain. Reason foradmission: emergencyappendectomy
Nonacute CareSituation: Female teacher withcomplaint of undesired weightgain referred by hospital RDNb
(Same person as in Acute Care)
Diagnosis P:(demonstrativeexample only)f
E:S:
Inadequate mineral intake: Ironrelated toinfrequent consumption ofiron-rich foodsas evidenced bylow dietary iron consumption(<67% EAR) and low Hgb(<120 g/dL) in 40% ofwomen of reproductive age
Limited access topotable waterrelated tolack of disasterplanningas evidenced by<5 d supply of 1gal (4 L) /person/d
Malnutritionrelated toinadequate oral intakeas evidenced byresident consuming <50% ofmeals, 5% weight loss,evidence of muscle wasting(SGAg B) and reports offatigue and dysphagia
Excessive energy intakerelated toconsuming high-fat foodswhen not hungryas evidenced by unintendedweight gain of 60 lb (27 kg) in24 mo and energy intakeexceeding total estimatedenergy needs by700 kcal/d (2,900 kJ/d)
Undesirable food choicesrelated toconsuming high fat foodswhen not hungryas evidenced byunintended weight gain of60 lb (27 kg) in 24 mo andenergy intake exceeding totalestimated energy needs by700 kcal/d (2,900 kJ/d)
Intervention Mass communication topromote Food environmentchange in Communities,neighborhoods and familiessector.Goal: 50% Reduction inanemia in women ofreproductive ageh
Team meeting:with foodproductionmanager, watervendors,materialsmanager to planaction pointsGoal: 5-d Supplypotable water toprovide 1 gal(4 L)/d/person
Nutrition Prescription: 1,500kcal 80 g protein/d, purèeddiet, Meals and snacks:Purèed food Level 4 Green,Moderately thick liquid Level3 YellowFood and Nutrient Delivery:Change diet order to purèedwith fortified foods andbetween-meals snacks.Implement medicationnutrition supplement passprogram.Collaboration with otherproviders: Nursing to monitortolerance to purèed diet
Nutrition prescription: 1,600kcal/d (6,700 kJ/d), Healthbelief model, Motivationalinterviewing, Referral to RDNwith different expertise.Goal: Make appointment withweight management RDNbefore discharge
Nutrition prescription: 1,600kcal/d (6,700 kJ/d), Sociallearning theory, Goal setting,Recommended modifications:lower-fat snack choices.Goal: Altered eating habitsresult in weight loss of 5% ofcurrent body weight
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Figure 3. (continued) Terminology applications in a variety of practice settings. Nutrition Care Process Terminology terms are presented in boldface italic type.
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CaseNCP
Public HealthSituation: Women ofreproductive age found withlow Hgba and iron-deficientdiet
FoodserviceSituation: In anatural disaster,it is estimatedthat 5 d areneeded to repairand restorepotable watersupply
Long-Term CareSituation: Daughter ofpersonal care home residentconcerned with mother’sfood intake. Resident hasswallowing difficulties
Acute CareSituation: Hospitalizedfemale teacher withcomplaint of undesiredweight gain. Reason foradmission: emergencyappendectomy
Nonacute CareSituation: Female teacher withcomplaint of undesired weightgain referred by hospital RDNb
(Same person as in Acute Care)
Monitoring andevaluation
Food Intake, Mineral elementintake,Nutritional anemia profile:Hgb: After 3 y, modestlyincreased consumption ofiron-rich foods (<EAR) andincidence of low Hgb (Hgb<120 g/L) not trendingtoward reduction. ProgrammodifiedIndicator: Dietary intake ofironCriterion: >EARIndicator: HgbCriterion: Hgb >120 g/L
Availability ofpotable water:Water supply of1 gal (4 L)/person/d for 5 dachievedIndicator: WatersupplyCriterion: at least1 gal (4 L)/person/d for 5 d
Food intake, Diet Order: Mealobservation by nursingreports tolerance andacceptance of diet.Fluid/beverage intake: 95%consumption of commercial(prepackaged) beverageWeight change: weight gain3%Indicator: Percent intake ofserved meals snacks, andbeveragesCriterion: at least 95%Indicator: Weight gainCriterion: weight gain by 3%
Readiness to change nutritionrelated behavior: madeappointment with weightmanagement RDN beforedischargeIndicator: AdherenceCriterion: Make appointmentwith weight managementRDN
Body mass index, Meal snackpattern, Types of food meals.Eating fruit and whole grainsnacks when hungry, weightreduction, confident of abilityto continueIndicator: Body mass indexCriterion: Body mass index<31.7Indicator: weight reductionCriterion: 5% weightreduction of current bodyweight
aHgb¼hemoglobin.bRDN¼registered dietitian nutritionist.cEAR¼ Estimated Average Requirement.dEPA¼Environmental Protection Agency (https://www.epa.gov/sites/production/files/2015-03/documents/planning_for_an_emergency_drinking_water_supply.pdf).eC-CDA¼Consolidated Clinical Document Architecture.fPES¼Problem, Etiology, Signs, and Symptoms.gSGA¼Subjective global assessment.hhttp://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.
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2003 Ultimate impacts (Part II,2008)
Status ofUltimateImpacts
Assumptions Stakeholders 2018 Ultimate Impacts
Quality, cost-effective nutritioncare delivered in partnershipwith providers, agencies, andcommunitiesNutrition care grows nationallyStandardized nutritionlanguage included in dietitianeducationOngoing maintenance andupdates of standardizedterminology accomplished bythe Academya and/or partnersEvaluate a national datawarehouse established for asustainable, reliable and usefuldatabase for Academy/dietitians/researchersNational, state, and localpolicies developed andsupported to foster nutritionpractice, education, andresearchIncorporate NCPb andInternational Dietetics andNutrition StandardizedLanguage in to dieteticspractice worldwide
Ongoing
Ongoing
Realization
Ongoing
Realization
Ongoing
Realization
� Nutrition is an essential component ofhigh quality health care for promotionof health and prevention of disease
� Data are needed to research the pro-cess and outcomes of nutrition care
� Nutrition and dietetics professionals,educators, and researchers will useand enhance a standardized nutritionlanguage
� Nutrition and dietetics professionals,educators, and researchers continue touse and improve the NCP
� Nutrition and dietetics professionalsand researchers use standardized ter-minology in a database to performoutcomes management and targetedresearch
� Nutrition and dietetics professionalsimprove effectiveness throughcollaboration
� Emphasis on people-centered, value-based health care
� Health care consumers� Academy members� Academy BODc
� Academy HODd
� Other health care providers� Health care payers� Legislators and regulators� Health care researchers� International health care termi-
nology and information man-agement standardsorganizations
� International nutrition anddietetics professionals andorganizations
Safe, effective, efficient, person-centered, timely, and equitablenutrition care delivered incollaboration with providers,agencies, and clients
Nutrition care improves the health andwell-being of all peopleStandardized nutrition languageintegral to nutrition and dieteticseducation
Robust maintenance and updates ofstandardized terminologyaccomplished by Academy and itsglobal partners
Popularize a sustainable, reliable,useful database for Academy andnutrition and dietetics research andinnovation
Jurisdictional policies developed andsupported to foster nutritionpractice, education, and researchSupport adoption of NCP and NCPTinto nutrition and dietetics practiceworld-wide
NCPTe is the essential element linkingtechnological innovations, andachieving interoperability innutrition and dietetics at large
aAcademy¼Academy of Nutrition and Dietetics.bNCP¼Nutrition Care Process.cBOD¼Board of Directors.dHOD¼House of Delegates.eNCPT¼Nutrition 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.
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reported the use of IDNT. Recently, thenutrition diagnosis terms of NCPT weremapped to the International Classifi-cation of Diseases as part of a nationalproject in Norway.26 Japan and SouthKorea also adopted the IDNT.27,28 Arecent global survey of NCP/NCPTadoption and use has been completedand the results are being prepared forpublication (personal communicationwith Elin Lovestam, June 5, 2018). Fromthe Academy’s Professional AssessmentSurvey, there is increasing trend of useof Academy resources related to NCPand NCPT from 2007 to 2017 (NCPROCommittee face-to-face meeting, June5, 2017). In this survey, 20% of re-spondents use NCPT in structured EHRs(predefined data elements to selectfrom), 45% in unstructured (free-text)EHRs, and 30% is a combination ofstructured and unstructured docu-mentation (NCPRO Committee face-to-face meeting, June 5, 2017). Thesedata reflect that a large portion ofpractitioners are still documentingelectronically in free-text fields. It isimportant to acknowledge thatupgrading EHR technology to struc-tured form is a major and challengingchange that requires resources andvested stakeholders. Academy surveydata integrated with the awaited in-ternational survey will assist in devel-oping global strategies for NCP/NCPTuse and adoption.Difficulties and challenges of imple-
menting the NCPT have been identifiedby several studies. Challenges withimplementation have includedincreased time requirement to useNCPT, concern that other health pro-fessionals will not read nutrition diag-nosis statements, limited number oftranslations, concern that translationor dialects may lead to mis-interpretations of the terminology, andpatient-centered experience data maynot be captured effectively (NCPROCommittee face-to-face meeting, July13, 2017).11 Results from a qualitativestudy found that Swedish dietitiansexpressed ambivalence toward theterminology in that some terms, espe-cially in the environmental-behavioraldomain of the Nutrition Diagnosis ter-minology, were harsh or offensive to-ward patients.14 These surveys supportthat implementation strategies shouldinclude education and training, incor-poration of terminology into
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documentation tools for health records,and culturally sensitive translation.Change-management skills and lead-ership support are also needed forsuccessful implementation.29,30
Development and SubmissionProcessThe NCPT communicates the pro-fession’s unique contribution to healthcare. The terminology grew from 62Nutrition Diagnosis terms in 2006 to712 NCPT terms in 2008. There arecurrently about 1,700 terms (Figure 2)defining the four steps of the NCP. Theterminology has globally evolved fromprinciples and initiatives to acknowl-edge community and public healthnutrition and other specialty practices,and to achieve inclusion into stan-dardized EHR terminologies (Figure 5).Ongoing work to maintain the termi-nology for an ever-changing professionis possible because of the valuablecontribution of practitioners and con-tent experts and the improved processby which terms are developed.Throughout the early development
process, the Standardized Language TaskForce sought term suggestions frompractitioners and subjectmatter experts.Forms were included within the IDNTbooks to encourage term submissionfrom users of the terminology. Termsubmitters provided a term definition,reference sheet, and supporting evi-dence. Term refinement was a collabo-rative process between submitters andan expert terminology consultant. Theexpert terminology consultant also pro-vided a recommendation for placementof the term within the terminologystructure. This completed work wassubmitted to the committee for inclusionin the terminology.The submission processwasmodified
in2014 to streamline the involvementofNCPROC, its supporting workgroups,and an expert terminology consultant.The revised process evaluates term re-quests andmodifications fromgroups ofsubjectmatter experts such as Academydietetic practice groups, Academyleaders, and NCPT users.31Some important changes to the sub-
mission process include an initial re-view by the NCPROC to assess theterm’s merit in nutrition and dieteticspractice before allocating consultingtime or obtaining a review by the Clas-sification Workgroup to determine
N AND DIETETICS
whether a proposed or modified termalready exists in an international clinicalterminology standard such as SNOMED-CT and LOINC. If a term is progressed tothe Classification Workgroup and isfound to already exist in an interna-tional clinical terminology standard, theterm may be readily adopted withoutadditional development.
If a proposed term is progressed tothe Classification Workgroup and is notfound in existing international clinicalstandards, then development workmay be needed. When expert agree-ment is reached on the proposed con-tent, terms are approved by theNCPROC for inclusion in the nextrelease of the NCPT.31 Term and defi-nition development is a consensusamong experts or expert practicegroups that reflects current nutritionand dietetic practice and research.
Recent examples of this approachincludes terms describing the etiologyand severity of adult and pediatricmalnutrition, International DysphagiaDiet Standardization Initiative terms,terms to support the Nutrition-FocusedPhysical Examination, and thePopulation-Based Nutrition Actionintervention terms (Figure 5).
With the increase in internationalNCPT use, NCPROC was restructured toensure half the membership was basedinternationally. Likewise, the NCPROCAdvisory Workgroup, InternationalWorkgroup, and Classification Work-group contribute a global talent pool ofsubject matter experts. Thus, the NCPTevolves with new and revised termrequests from a dynamic, internationalprofession.
TranslationThe eNCPT has been translated from USEnglish into seven languages and di-alects.10 The translations are availableto all eNCPT subscribers. The Academycollaborates with international profes-sional organizations such as associa-tions and or universities, and theirtranslating team entities (eg, collabo-rators, consultants, or other appointedprofessionals) in an effort to make theNCPT a global language with interna-tional usage.32
Sweden completed its translation in2011 and has subsequently completedfour updates. Experiences from Swe-den have shown the importance of
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Principles and initiatives Select NCPT examples
Reflect aninternationalperspective
International leaders, experts, and reviewers are integral to the NCPTmaintenance and Committee processes.
US and international standards are included in resources for:� Measures� Laboratory units� Nutrient intake
NCPb and NCPT are used in several countries. Definitions are developed toincorporate new NCPT into standardized terminologies and for accurateconceptual translation.The NCPROc Committee collaborated with the International Dysphagia DietStandardisation Initiative to develop NCPT diet terms and definitions so thatthe Academyd could submit them to standardized terminologies.59
� Complex carbohydrate estimated intake in 24 h (g/day)� Vitamin A estimated intake in 24 h in mg (micrograms)� BUNa (mg/dL or mmol/L)� Creatinine measurement, serum (mg/dL or mmol/L)� Estimated daily glycemic load (number) Definition: The esti-
mated measure per day reflecting the quantity and type of allcarbohydrate consumed.
� Purèed food Level 4 Green� Extremely thick liquid Level 4 Green� Liquidized food Level 3 Yellow� Moderately thick liquid Level 3 Yellow
Take a people-centered approach
New term synonyms were deemed necessary for terminology consideredoverly judgmental.35
� Food and nutrition-related knowledge deficit synonymLimited food and nutrition-related knowledge
� Undesirable food choices synonym Unbalanced diet� Physical inactivity synonym Limited physical activity
Recognize theetiologyand severity ofmalnutrition(undernutrition)
Malnutrition was reclassified as a clinical condition with movement of thenutrition diagnosis from the Intake domain to the Clinical domain formore accurate modeling of these conditions.
� Moderate chronic disease or condition related malnutrition� Severe acute disease or injury related malnutrition� Mild nonillness-related pediatric malnutrition� Moderate illness-related pediatric malnutrition
Malnutrition indicators from the Academy consensus papers for adults andpediatrics have been included in the NCPT reference material.60,61
� Temporalis muscle atrophy� Handgrip strength� Head circumference for age z score� Weight for length z score
Characterize nutritioninterventions inpopulations
Nutrition interventions at the institutional, community, and policylevels describe actions to address nutrition problems influenced by theenvironment in which people live, work, and play.
Fully integrating the Social Ecological Model, a new Nutrition interventionsdomain, aligned the NCPT with the Centers for Disease Control andPrevention Health Impact Pyramid and the World Health OrganizationPopulation Health Promotion Model, which was adopted in the OttawaCharter on Health Promotion.62-64
Population-based nutrition action� Social ecological model� Social marketing� Mass communications� Food environment change� Public policy change� Food production and provision settings� Government settings� Agriculture sector� Communities, neighborhoods, families sector
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Figure 5. Major principles and initiatives of Nutrition Care Process Terminology (NCPT).
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Principles and initiatives Select NCPT examples
Represent content forspecialized practice
Practitioner-led efforts to reflect their practice and research with neonatal,long-term care, inborn errors of metabolism, gastrointestinal disorder,and community nutrition and public health populations are included inNCPT adding 781 assessment/monitoring and evaluation terms, 107diagnosis, and 326 intervention terms since all 4 steps were published inIDNTe in 2008.5
� Breastmilk feeding attempts in 24 h� Docosahexaenoic acid estimated intake in 24 h� Total fat from intravenous fluids� Total protein per kilogram estimated in 24 h� Phenylalanine, dried blood spot� Pressure injury of hip� Excessive growth rate� Consistent carbohydrate diet� Modify composition of parenteral nutrition� Modify route of parenteral nutrition
Clarify usage ofterminology
The NCPRO Committee has responded to practitioner concerns andquestions by:�Providing guidance for diagnoses associated with exocrine andendocrine functions,�Relocating an indicator for gluten from a carbohydrate to a proteindiagnosis because of the protein in gluten responsible for the intoleranceor allergy, and�Defining predicted nutrition diagnoses that are anticipated based onobservation, experience, or scientific reason.
� Altered gastrointestinal function� Impaired nutrient utilization� Intake of types of proteins inconsistent with needs� Predicted inadequate energy intake� Predicted breastfeeding difficulty� Predicted food medication interaction
Structure uniquenutrition data
Removing the need for hierarchical terminology construction by creatingcomplete terms and submitting them to standardized terminologies (ie,SNOMED CTf and LOINCg), each term is assigned a 5-digit Academyunique identifier.20,21 This facilitates data tracking in electronic recordsystems. While all terms in nutrition diagnosis and intervention haveexternal mappings, work continues in assessment.
� Potassium estimated intake in 24 h� Serum potassium measurement� Inadequate potassium intake� Potassium modified diet� Potassium supplement therapy� Estimated potassium needs
Ambiguous terms, such as suboptimal and less than optimal, have beenreplaced with more accurate labels.
� Growth rate below expected� Intake of types of fats inconsistent with needs (specify)
Terms that conveyed more than 1 idea have been separated forindependent expression.
� Limited access to food� 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).
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FROM THE ACADEMY
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creating a work group of experienceddietitians as well as having an ongoingdialogue and consensus buildingamong the key contacts (expert di-etitians with varied practice experi-ences and other health careprofessionals) involved in the trans-lation.33 To be useful to nutrition anddietetics practitioners, a conceptualtranslation that is accurate, unambig-uous, linguistically correct, and consis-tent is needed. Translating challengesinclude differences in culture, healthcare systems, legal issues, differencesin the use of nutrition and dieteticsterms, and references to US-specificconcepts in the terminology. Concep-tual translation is facilitated by cleardefinitions and supporting referencesheets.
The Academywelcomes translations ofthe eNCPT. To obtain acceptance fromthe Academy to translate, translatorsneed support from their national di-etetics association or equivalent profes-sional governing entities or university.The responsibility for the quality of thetranslation and associated costs lie withthe translating organization. A concernfor the future is that the costs to com-plete an initial translation, subsequentmaintenance, and access to the eNCPTmay not be affordable for dietetics asso-ciations or other interested organizationsin developing economies. There is a needfor a sustainability model that facilitatesand/or funds translations in less-affluentcountries.
SYNONYMS: THE GLOBAL MOVETOWARD PEOPLE-CENTEREDCAREThe adoption of a people-centeredcare approach, sometimes morenarrowly referred to as patient-centered or person-centered care, isgrowing globally.34 This approachincludes providing an individual fullaccess to his or her health care in-formation. The Organization for Eco-nomic Co-operation andDevelopment has developed qualityhealth care indicators, including in-dicators to track patient-centeredcare, that allow comparisons acrossmember countries.35,36 The inclusionof patient-centered health care mea-sures into health care system perfor-mance assessments has occurred inmany countries, including Australia,Canada, Denmark, France, Germany,Switzerland, the Netherlands, New
EMY OF NUTRITION AND DIETETICS 11
Behavioral and Environmental Domain
Knowledge and Beliefs
NCP TermFood and nutrition-related knowledgedeficitSelf-monitoring deficitUndesirable food choicesPhysical inactivityInability to manage selfcareImpaired ability to prepare food/meals
SynonymLimited food and nutrition-relatedknowledgeLimited self-monitoringUnbalanced dietLimited physical activityLimited ability to manage self-careLimited ability to prepare food/meals
Figure 6. Nutrition Care Process (NCP) Terminology-approved synonyms can be usedinterchangeably in place of the original term without altering the meaning of theterm. NCP¼Nutrition Care Process.
FROM THE ACADEMY
Zealand, United Kingdom, and theUnited States.34
Leadership and cultural trans-formation are part of the patient-centered care journey.37 In countrieswhere clients have full access to theirhealth record, it is very important touse terminology that is not perceivedto be harsh or offensive. There isgreater recognition for the need ofpeople to be considered as individualswith varied needs and not as clinicalsymptoms. The choice of words usedduring an episode of care ought toreflect this philosophy. A psychologist’sview regarding successful use of stan-dardized language is that it shouldcorrespond to situations in practice,have internal coherence, and intuitiveappeal to users.38
The provision of care and the languagedescribing that care needs to berespectful and responsive to individualpreferences and values. With the globaladoption and implementation of NCPT,the terminology needs to communicatethe care provided to culturally andlinguistically diverse populations. Feed-back from international surveys hasindicated the desire for terms that aremore patient-centered. The 2014Australian NCPT Implementation Surveyshowed improvement in NCPT attitudes,knowledge, and use over time.39 In thatlongitudinal survey, free-text commentswere collected to understand the chal-lenges or barriers related to NCPT use, inparticular areas of practice. The dietitianrespondents’ comments included gen-eral sentiments such as, “I would cringeto write.,” “Some of the terminology isquite derogatory of the client/patient,”“An impersonal way of describing aninteraction” and, “Culturally words haveslightly different meanings. I changesome words when I deem the languagejudgmental.”Synonym submissions from New
Zealand have provided alternatives tothe words deficit and inability. Specif-ically, “Self-monitoring deficit,” “Food-and nutrition-related knowledgedeficit” and, “Inability to manage self-care” are examples of terms that couldmake an individual feel pessimistic,discouraged, or embarrassed. An in-dividual’s personal strengths andcapability may be overshadowed by aperceived critical expression. The syn-onym limited for inability is less judg-mental, more empathetic, and isconstructive with a positive regard for
12 JOURNAL OF THE ACADEMY OF NUTRITIO
the individual. Utilizing the term sub-mission process, a number of syno-nyms for diagnostic terms within theBehavioral-Environmental Domainwere approved and included in the2016 eNCPT release (Figure 6). Syno-nyms can be used interchangeably inplace of the original term withoutaltering the meaning.
NCPT INCLUSION IN CLINICALTERMINOLOGY ANDELECTRONIC HEALTHINFORMATION MANAGEMENTSTANDARDSThe Academy has been submitting NCPTterms to SNOMED-CT and LOINC since2011, and has developed electronichealth information management stan-dards for Health Level 7 (HL7).20,21,40
SNOMED-CT and LOINC are clinical ter-minology standards required for use inUS EHRs and similarly used in manyother countries. Both standards are usedinternationally in EHRs. Generallyspeaking, SNOMED-CT terms encompassterms from all NCP steps. LOINC includesprimarily quantitative Nutrition Assess-ment and Nutrition Monitoring andEvaluation terms.In the United States, terminology
standards also facilitate coding thefinancial value of care for proceduresand services using Current ProcedureTerminology of the American MedicalAssociation41 and Healthcare Com-mon Procedure Coding Systems G-codes.42 These codes are maintainedjointly by the alpha-numeric editorialpanel with participation from theCenters for Medicare and MedicaidServices and other payer codingschemes.43 As part of SNOMED-CT and
N AND DIETETICS
LOINC, NCPT provides terms useful inthe United States for coding socialdeterminants of health from nonphy-sician clinical documentation usingthe International Classification ofDiseases.44,45
The submission of NCPT to clinicalterminology standards started withnutrition assessment terms to meet anurgent regulatory standard for EHRs inthe United States.46 A consequence ofthis process was that submissions ofNCPT to the International HealthTechnology Standards DevelopmentOrganization, now SNOMED Interna-tional, were for the most part availablein the US edition of SNOMED-CT andnot other countries. SNOMED-CT hasmultiple country editions in addition toan overarching International Edition.20
LOINC has a single edition withtranslations.21
The widespread transition to EHRshas made it apparent that there is aneed to have NCPT incorporated intothe SNOMED-CT International Edition.This would make NCPT available to allentities using SNOMED-CT. Recently,dietetics associations from Australia,Brazil, Canada, Denmark, Israel,Mexico, New Zealand, Norway,Switzerland, Sweden, and the UnitedStates requested inclusion of NCPTterms into the International Edition ofSNOMED-CT. This request wasaccepted and in July 2018 all NCPTterms that were in the US edition arenow available in the SNOMED-CT In-ternational Edition.20 This is a majorstep forward for continued interna-tional NCPT availability and adoption.
The Academy maps and models theNCPT to SNOMED-CT and LOINC on anongoing basis. Mapping and modeling
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FROM THE ACADEMY
is a process to confirm that an equiv-alent relationship with a term existsin a terminology standard and ensuresthat NCPT communicates the samemeaningful information and signifi-cant facts in SNOMED-CT or LOINC.The resulting database and availablenutrition standards are used by de-velopers to match accurately NCPT toSNOMED-CT or LOINC terms whendesigning an EHR.47 This may notappear as a point of interest to nutri-tion and dietetics professionals atfirst. However, in EHRs the NCPT iswhat the user sees and uses upfrontwhen they document and in the backend are the SNOMED terms. EHRsstore SNOMED data for later reportingand research. Thus, this matching be-tween NCPT and SNOMED is a neces-sary foundation to be able to conductlarge-scale quality improvement suchas reporting on electronic quality mea-sures, and/or NCP-related research. Pro-fessionals are encouraged to advocate forNCPT matching to SNOMED at theirworkplace EHR and work proactivelywith information technology staff tomake this happen.Inclusion of NCPT in the clinical ter-
minology standards facilitates repre-sentation of NCPT in electronic healthinformation management standardssuch as those of HL7.40 This represen-tation is fundamental to the
NCP anTerminology/electronic health inf
(SNOMED CT
Hospitalized obese female comreferred to outpatient RDN with
Transition of cNCP an
Terminology/electronic health inf(SNOMED-CT
Obese female referred from managem
Figure 7. Interoperability schema. NCP¼NSystematized Nomenclature of MedicineHL7¼Health Level 7 International. RDN¼reg
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interoperability of electronic healthdata and records. Interoperability aimsto provide a seamless, secure flow ofmeaningful electronic information toimprove care (Figure 7).To foster nutrition care across care set-
tings in the United States, the Academyprovides routine input on nutritioninformatics developments and relatedneeds to the federal Office of the NationalCoordinator of Health Information Tech-nology. This input is aimed to update theInteroperability Standards Advisory.47,48
A recent major development is the revi-sion of the Electronic Nutrition Care Pro-cess Record System (ENCPRS) forinternational use. The ENCPRS is a func-tionalelectronichealthdatamanagementstandard available from HL7 that definesthe necessary content and messaging fornutrition and dietetics-related documen-tation. ENCPRSreliesonNCPandNCPT forcontent. Also, in theUnited States,work isunderway to develop anHL7 standard fortransition of care documentation that in-cludes templates for describing nutritioncare plans using NCP and NCPT. Termi-nology standards and data managementare essential structures to ensure inter-operability among EHRs (Figure 7).
NCPT IN RESEARCHThe NCPT as a structured terminologyhas begun to demonstrate its utility in
d NCPTormation management standards, LOINC/HL7)
plains of unwanted weight gain, weight management expertise
are document d NCPTormation management standards, LOINC/HL7)
hospitalization desires weight ent care
utrition Care Process. NCPT¼Nutrition CarClinical Terminology. LOINC¼Logical Obseistered dietitian nutritionist.
JOURNAL OF THE ACAD
providing data for research (Figure 4).As described in the NCPmodel update,2
a data aggregation platform, the Acad-emy of Nutrition and Dietetics HealthInformatics Infrastructure (ANDHII),the architecture of which contains theNCPT, was used in studies to “explorethe feasibility of validating malnutri-tion diagnostic criteria”22 and “inves-tigate the influence of evidence-basednutrition practice guidelines for theprevention of diabetes on both practicepatterns and patient outcomes.”18
ANDHII is forging new frontiers glob-ally. ANDHII is being increasingly usedin nutrition research, education, andclinical and public health settings inthe United States and around theworld. This web-based NCPT tool canbe especially helpful in settings wherethe EHR is not structured yet to capturenutrition care and/or in public healthsettings where a nutrition-focusedevaluation framework is needed. Edu-cators use ANDHII to teach future cli-nicians in classrooms, internshipsettings, and/or student-led clinics.ANDHII-focused activities empowerstudents to enhance their informaticsskills, apply their NCPT in practiceconditions, and monitor the efficacy oftheir work. Other data aggregationtools that contain NCPT content canalso be employed in research or qualityimprovement projects. Leveraging the
Data aggregation(e.g.Health Information
Exchange [HIE], Academy of Nutrition and Dietetics
Health Informatics Infrastructure [ANDHII])
Coded valueQuality improvement
Practiced based research
Data aggregation(HIE, ANDHII)
Coded value, QIPracticed based
research
Improvecare
e Process Terminology. SNOMED CT¼rvation Identifiers Names and Codes.
EMY OF NUTRITION AND DIETETICS 13
FROM THE ACADEMY
data derived from NCPT is an avenue todemonstrate effectiveness of nutritionand dietetics care.
GOING FORWARDThe adoption and consistent use of theNCPT promotes and strengthens nutri-tion communications among healthprofessionals, their clients, and othercustomers. Several of the 2008 aspira-tions and goals for the NCPT have beenrealized (Figure 4). These include theincorporation of NCPT into EHRs andstandardized clinical terminologies tocommunicate nutrition care. Also,expansion and revisions have occurreddue to changes in the field of nutritionand dietetics. The role of NCP and NCPTin informatics is now better appreci-ated as NCPT becomes a part of clinicalterminology and electronic health in-formation management standards. Thehigh interest in international trans-lation, adoption, and enhancement ofNCPT continues to grow. Furtherdevelopment of the NCPT in the areasof diagnosis etiology, nutrition assess-ment and monitoring, and evaluationstatus is needed. Standardization ofetiologies will help reveal which typesof interventions effectively resolvespecific etiologies, a key part of diag-nosing. This is important because thesame nutrition problem can have adifferent etiology. Also, standardizedlabels for status have not been estab-lished, but these are needed becausecare providers and institutions usedifferent ways to document status.Research efforts to validate the ter-
minology are needed. Validation im-proves the quality of the terminologyand ensures that the terminology isused appropriately.49 The NCPM in-cludes guidance “to research the NCP.”2
Some work has been done towardvalidation of NCP terms in the UnitedStates. One study has tested the con-tent validity of diagnostic terms using aconvenience sample of registered di-etitians (RDs).50 Another studymeasured the reliability of nutritiondiagnosis terms among RDs.51 Finally,investigations have focused on thevalidation of nutrition diagnoses usedby RDs specializing in cancer,52 pedi-atrics,53 and gerontology.54 These in-vestigations were in agreement thatsome refinement of the evaluatednutrition diagnoses may be warranted.An additional consideration for
14 JOURNAL OF THE ACADEMY OF NUTRITIO
research is NCPT acceptance by clientsand other health care providers.The need for structured diagnosis
etiologies in the NCPT is beingexplored. Recent research demon-strates that there is little agreement inetiology selection among professionalswhen assessing nutrition-related datafrom the same client.55 A specificnutrition diagnosis term may berelated to a variety of etiologies. It isthe etiology that primarily determinesthe intervention to resolve or mitigatenutrition diagnoses.2 Being able to linknutrition diagnosis etiologies or etiol-ogy categories and efficacious in-terventions would be useful in practice.Descriptors that define the status ofdiagnosis resolution are beingdeveloped.The documentation of the interven-
tion step needs to be further refined.The intervention consists of the planand the implementation. The plan(which includes the nutrition pre-scription and goals) and the imple-mentation of the plan could be furtherdefined, structured, and quantified toassist professionals in designingmeasurable and comparable in-terventions. Also, defined scales tomonitor effectiveness of an interven-tion is being considered for inclusion inthe NCPT. Such progress in the termi-nology will facilitate outcomesresearch in a substantive way.The need for ongoing professional
education and training is important tohighlight. Earlier cited surveys on theusage and adoption of the NCPT indi-cate that even countries with long-standing implementation, such as theUnited States, can improve the utiliza-tion of NCPT. Hence, education effortsin the future will not only target stu-dents, but also practicing and returningpractitioners. Collaborative profes-sional networks, also known as Com-munities of Practice and continuouslyupdated experiential training deliveredby NCP/NCPT certified trainers can beimportant methods to effectively reachand support a broad number of pro-fessionals. Through interactive educa-tional methods, where learning takesplace through connections formedamong colleagues, learners can expandtheir connections and these connec-tions drive new learning and decisionmaking.56 Interprofessional educationthat incorporates nutrition and di-etetics also warrants consideration.57
N AND DIETETICS
CONCLUSIONSOver the past decade, the Academy hassuccessfully pioneered a standardizedterminology to communicate the NCPperformed by nutrition and dieteticspractitioners. NCPT has been adopted,implemented, and enhanced by inter-national professionals and organizations.NCPT has been embraced by terminol-ogy and health information manage-ment standards. The terminology hasgrown to include specialty practices andvaried practice settings as well asculturally sensitive synonyms. NCPTgrowth is supported by a responsiveprocess to accommodate new terms thataddress inevitable practice changes.Research tools have been created toexplore NCPT implementation, its utilityin describing the value of nutrition anddietetics practice, and the effectivenessin communicating quality practice thatimproves the health of communities. Theneed for training and continuing educa-tion regarding NCP and NCPT is ongoing.NCPT has become internationally essen-tial to the field of nutrition and dietetics,intersecting technology, practice, andresearch for innovation and discovery.
References1. Academy of Nutrition and Dietetics.
Nutrition Terminology Reference Manual(eNCPT): Dietetics language for nutritioncare. http://www.ncpro.org. AccessedJune 28, 2018.
2. SwanWI, Vivanti A, Hakel-Smith NA, et al.Nutrition Care Process and Model update:Toward realizing people-centered careand outcomes management. J Acad NutrDiet. 2017;117(12):2003-2014.
3. National Library of Medicine. Unifiedmedical language system. https://www.nlm.nih.gov/nichsr/hta101/ta101013.html.Accessed June 28, 2018.
4. Jenkins M, Myers E, Charney P, Escott-Stump S. American Dietetic Association’sStandardized Nutrition Language: Projectlogic model and current status. StudHealth Technol Inform. 2006;122:710-714.
5. Writing Group of the Nutrition Care Process/Standardized Language Committee. Nutri-tion Care Process part II: Using the Interna-tionalDietetics andNutritionTerminology todocument the Nutrition Care Process. J AmDiet Assoc. 2008;108(8):1291-1293.
6. Writing Group of the Nutrition Care Pro-cess/Standardized Language Committee.Nutrition Care Process and Model part I:The 2008 update. J Acad Nutr Diet.2008;108(7):1113-1117.
7. American Dietetic Association. NutritionDiagnosis: A Critical Step in the NutritionCare Process. Chicago, IL: American Di-etetic Association; 2006.
8. American Dietetic Association. Interna-tional Dietetics and Nutrition Terminology(IDNT) Manual. Chicago IL: American Di-etetic Association; 2008.
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9. Academy of Nutrition and Dietetics.Abridged Nutrition Care Process Terminol-ogy (NCPT) Reference Manual. Chicago IL:Academy of Nutrition and Dietetics; 2017.
10. Academy of Nutrition and Dietetics.Nutrition Terminology Reference Manual(eNCPT): Dietetics language for nutritioncare. International collaboration andtranslations. http://www.ncpro.org/international-collaboration. AccessedJune 28, 2018.
11. European Federation of the Associationsof Dietitians. Report on knowledge and useof a Nutrition Care Process & StandardisedLanguage by Dietitians in Europe; 2012.http://www.efad.org/media/1185/ncp__sl_report.pdf. Accessed December 5, 2018.
12. International Confederation of Dietetic As-sociations. ICDA strategic plan 2017-2020.http://www.internationaldietetics.org/About-ICDA/Mission-and-Goals.aspx. Accessed July3, 2018.
13. Hakel-Smith N, Lewis NM, Eskridge KM.Orientation to Nutrition Care Processstandards improves nutrition care docu-mentation by nutrition practitioners. J AmDiet Assoc. 2005;105(10):1582-1589.
14. Lovestam E, Bostrom AM, Orrevall Y.Nutrition Care Process implementation:Experiences in various dietetics environ-ments in Sweden. J Acad Nutr Diet.2017;117(11):1738-1748.
15. Lövestam E, Orrevall Y, Koochek A,Andersson A. The struggle to balancesystem and lifeworld: Swedish dietitians’experiences of a standardised nutritioncare process and terminology. HealthSociol Rev. 2016;25:240-255.
16. Myers EF, Trostler N, Varsha V, Voet H.Insights from the Diabetes in IndiaNutrition Guidelines Study: Adopting in-novations using a knowledge transfermodel. Top Clin Nutr. 2017;32(1):69-86.
17. Rossi M, Campbell KL, Ferguson M.Implementation of the Nutrition CareProcess and International Dietetics andNutrition Terminology in a single-centerhemodialysis unit: Comparing paper vselectronic records. J Acad Nutr Diet.2014;114(1):124-130.
18. Thompson KL, Davidson P, Swan WI, et al.Nutrition Care Process chains: Tthe“missing link” between research andevidence-based practice. J Acad Nutr Diet.2015;115(9):1491-1498.
19. Tilakavati K, Tonia R, Shanthi K, Shy-Pyng T, Chee-Hee S. Incorporating theNutrition Care Process model into di-etetics internship evaluation: A Malaysianuniversity experience. Nutr Diet. 2016;73:283-295.
20. SNOMED International. SNOMED-CT: Theglobal language of healthcare. http://www.ihtsdo.org/snomed-ct/. AccessedJuly 29, 2018.
21. Regenstrief Institute. Logical ObservationIdentifiers Names and Codes (LOINC). http://www.loinc.org/. Accessed July 3, 2018.
22. Hand RK, Murphy WJ, Field LB, et al.Validation of the Academy/A.S.P.E.N.malnutrition clinical characteristics.J Acad Nutr Diet. 2016;116(5):856-864.
-- 2019 Volume - Number -
23. Murphy WJ, Yadrick MM, Steiber AL,Mohan V, Papoutsakis C. Academy ofNutrition and Dietetics Health InformaticsInfrastructure (ANDHII): A pilot study onthe documentation of the Nutrition CareProcess and the usability of ANDHII byregistered dietitian nutritionists. J AcadNutr Diet. 2018;118(10):1966-1974.
24. Papoutsakis C, Moloney L, Sinley RC,Acosta A, Handu D, Steiber AL. Academyof Nutrition and Dietetics methodologyfor developing evidence-based nutritionpractice guidelines. J Acad Nutr Diet.2017;117(5):794-804.
25. Cunningham E. Where can I find re-sources for medical record documenta-tion? J Acad Nutr Diet. 2015;115(8):1360.
26. Lorentzen SS, Papoutsakis C, Myers EF,Thoresen L. Adopting Nutrition Care Pro-cess Terminology at the national level:The Norwegian experience in evaluatingcompatibility with International Statisti-cal Classification of Diseases and RelatedHealth Problems, 10th revision, and theexisting Norwegian coding system [pub-lished online ahead of print April 20,2018]. J Acad Nutr Diet. https://doi.org/10.1016/j.jand.2018.02.006.
27. Hammond MI, Myers EF, Trostler N.Nutrition Care Process and Model: Anacademic and practice odyssey. J AcadNutr Diet. 2014;114(12):1879-1894.
28. Kim EM, Baek HJ. A survey on the status ofNutrition Care Process implementation inKorean hospitals. Clin Nutr Res. 2013;2(2):143-148.
29. Gardner-Cardani J, Yonkoski D, Kerestes J.Nutrition Care Process implementation: Achange management perspective. J AmDiet Assoc. 2007;107(8):1429-1433.
30. Porter JM, Devine A, O’Sullivan TA. Eval-uation of a Nutrition Care Process imple-mentation package in hospital dieteticdepartments. Nutr Diet. 2015;72:213-221.
31. Academy of Nutrition and Dietetics.Nutrition Terminology Reference Manual(eNCPT): Dietetics language for nutritioncare. Terminology submission in-structions. In: http://www.ncpro.org/terminology-submission-process. AccessedJune 28, 2018.
32. Academy of Nutrition and Dietetics.Nutrition Terminology Reference Manual(eNCPT): Dietetics Language for NutritionCare. Are you interested in translating theeNCPT?. Read me!, http://www.ncpro.org/are-you-interested-in-translating-the-encpt-read-me. Accessed June 28, 2018.
33. McGreevy J, Orrevall Y. Translating Ter-minology for the Nutrition Care Process:The Swedish Experience (2010-2016). JAcad Nutr Diet.117(3):469-476.
34. World Health Organization. People CentredCare in Low- and Middle-Income Countries-Meeting Report. Geneva, Switzerland:World Health Organization; 2010.
35. Arah OA, Westert GP, Hurst J, Klazinga NS.A conceptual framework for the OECDHealth Care Quality Indicators Project. IntJ Qual Health Care. 2006;18(suppl 1):5-13.
36. Groene O, Skau JK, Frolich A. An interna-tional review of projects on hospital
JOURNAL OF THE ACAD
performance assessment. I Int J QualHealth Care. 2008;20(3):162-171.
37. Planetree. Reputation. www.planetree.org/reputation/. Accessed July 3, 2018.
38. Beckstead JW. Taxonomies of nursing di-agnoses: A psychologist’s view. Int J NursStud. 2009;46(3):295-301.
39. Vivanti A, Lewis J, O’Sullivan TA. TheNutrition Care Process Terminology:Changes in perceptions, attitudes,knowledge and implementationamongst Australian dietitians afterthree years. Nutr Diet. 2018;75(1):87-97.
40. Health Level Seven International. http://www.hl7.org/. Accessed May 5, 2018.
41. American Medical Association. CurrentProcedural Codes (CPT) 2018. ProfessionalEdition. Chicago, IL: American MedicalAssociation; 2018.
42. Healthcare Common Procedure CodingSystems G-codes. https://hcpcs.codes/g-codes/. Accessed May 25, 2018.
43. Centers for Medicare and Medicaid Ser-vices. www.cms.gov. Accessed July 5,2018.
44. World Health Organization. Internationalclassification of diseases, 10th revision,clinical modification (ICD-10-CM). http://www.cdc.gov/nchs/icd/icd10cm.htm.Accessed June 28, 2018.
45. American Hospital Association. Interna-tional statistical classification of diseasesand related health problems, 10th revi-sion, clinical modification. http://www.aha.org/dataset/2018-04-10-resource-icd-10-cm-coding-social-determinants-health.Accessed June 26, 2018.
46. Washington V, DeSalvo K, Mostashari F,Blumenthal D. The HITECH era and thepath forward. N Engl J Med. 2017;377(10):904-906.
47. Academy of Nutrition and Dietetics.Nutrition Terminology Reference Manual(eNCPT): Dietetics Language for NutritionCare. The NCPT and electronic health re-cords. http://www.ncpro.org/the-ncpt-and-electronic-health-records. AccessedJune 28, 2018.
48. Office of the National Coordinator forHealth Information Technology. Interop-erability standards advisory. http://www.healthit.gov/isa/. Accessed July 5,2018.
49. Ritter-Gooder P, Lewis NM. Validation ofnutrition standardized language-nextsteps. J Am Diet Assoc. 2010;110(6):832-835.
50. Enrione EB. Content validation of nutri-tion diagnoses. Top Clin Nutr. 2008;23:306-319.
51. Charney PJ, Maillet O’Sullivan JK,Touger-Decker R, Splett P, Meyers E,Haque S. Reliability of nutrition diag-nostic labels when used by registereddietitians at three levels of practice.J Am Diet Assoc. 2006;106(suppl):A-12.
52. Enrione EB, Villar J. Content validation oftwo nutrition diagnoses commonly
EMY OF NUTRITION AND DIETETICS 15
FROM THE ACADEMY
identified in oncology patients. J AcadNutr Diet. 2013;113(suppl):A-13.
53. Soares L, Auslander MH, Enrione EB.Application of the International Dieteticsand Nutrition Terminology for NutritionDiagnoses among Board Certified Spe-cialists in Pediatric Nutrition. J Acad NutrDiet. 2015;115(suppl):A-22.
54. Ritter-Gooder PK, Lewis NM,Eskridge KM. Content validation of a
16 JOURNAL OF THE ACADEMY OF NUTRITIO
standardized language diagnosis bycertified specialists in gerontologicalnutrition. J Am Diet Assoc. 2011;111(4):561-566.
55. Enrione EB, Reed D, Myers EF. Limitedagreement on etiologies and signs/symptoms among registereddietitian nutritionists in clinical prac-tice. J Acad Nutr Diet. 2016;116(7):1178-1186.
N AND DIETETICS
56. Salter KL, Kothari A. Knowledge’Translation’ as social learning: Negoti-ating the uptake of research-basedknowledge in practice. BMC Med Educ.2016;16:76.
57. Kicklighter JR, Dorner B, Hunter AM, et al.Visioning Report 2017: A preferred pathforward for the nutrition and dieteticsprofession. J Acad Nutr Diet. 2017;117(1):110-127.
AUTHOR INFORMATIONW. I. Swan is a past chair of the Nutrition Care Process Research Outcomes Committee, a member of the Classification Workgroup of the Academyof Nutrition and Dietetics, and a retired dietitian based in Ranchos de Taos, NM. D. G. Pertel is an expert terminology consultant for the NutritionCare Process Terminology, and principal, Pertel Nutrition Consulting, Brookline, MA. B. Hotson is a member, Nutrition Care Process ResearchOutcomes International Workgroup of the Academy of Nutrition and Dietetics, and a regional clinical manager, acute care, nutrition and foodservices, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; at the time of the study, she was a member, Nutrition Care ProcessResearch Outcomes Committee. L. Lloyd is chair, Nutrition Care Process Research Outcomes Committee, a member, Nutrition Care ProcessResearch Outcomes International Workgroup of the Academy of Nutrition and Dietetics, and a senior renal dietitian, Department of Nutrition andDietetics, Auckland City Hospital, Auckland, New Zealand. Y. Orrevall is a member, Nutrition Care Process Outcomes International Workgroup ofthe 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 theAcademy of Nutrition and Dietetics, and a professor emeritus, Faculty of Agriculture, Food, and Environmental Sciences, Hebrew University ofJerusalem, Rehovot, Israel; at the time of the study, she was a member, Nutrition Care Process Research Outcomes Committee of the Academy ofNutrition and Dietetics. A. Vivanti is chair, Nutrition Care Process Research Outcomes International Workgroup of the Academy of Nutrition andDietetics; vice chair, Nutrition Care Research Outcomes Committee; and a research and development dietitian, Department of Nutrition andDietetics, Princess Alexandra Hospital Brisbane, Brisbane, Queensland, Australia; and senior lecturer, School of Human Movement and NutritionStudies, University of Queensland, Brisbane, Queensland, Australia. K. B. Howarter is principal, Ms. Nutrient Food and Nutrition ConsultingServices, Evanston, IL; at the time of the study, she was director, Nutrition Care Process, Research International Scientific Affairs, Academy ofNutrition and Dietetics, Chicago, IL. C. Papoutsakis is a senior director, Data Science Center, Research International Scientific Affairs, Academy ofNutrition and Dietetics, Chicago, IL.
Address correspondence to: Constantina Papoutsakis, PhD, RD, Academy of Nutrition and Dietetics, 120 S Riverside Plaza, Suite 2190, Chicago, IL60606. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTERESTC. Papoutsakis is an employee and D. G. Pertel is a consultant, Academy of Nutrition and Dietetics, Chicago, IL, which has a financial interest inthe Nutrition Care Process Terminology.
FUNDING SUPPORTThe Academy of Nutrition and Dietetics is the source of funding for the present update on the Nutrition Care Process Terminology. The authorsand experts who conducted the update on the Nutrition Care Process Terminology had complete autonomy during all stages of the update andwriting of the present manuscript.
AUTHOR CONTRIBUTIONSAll 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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