Nutrition Connection: ADA Standardized Language • Winter 2008
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A new initiative launched by the American Dietetic Association (ADA) aims to standardize language used in documenting nutrition care. If you are working with a Registered Dietitian in supporting clinical care, you may begin to see ADA standardized terminology in your institution’s documentation standards, and may encounter new terminology in your workplace in coming months. This edition of Nutrition Connection provides the basics of the new standardization, so you'll be prepared for this shift if it occurs in your workplace.
According to the ADA, consistent language or terminology provides a consistent framework for provision of care, and follows models used by other professions. In addition, the ADA plans to submit standardized terminology for nutrition care to national healthcare databases, which may be incorporated into billing and reimbursement models. The ADA may also apply standardized documentation to research on the impact of nutrition on health and disease.
Standardized language can be used in documentation. In turn, documentation, says the ADA, is "an ongoing process that supports all of the steps in the nutrition care process."
Steps in the Nutrition Care Process
According to the ADA, the process of nutrition care follows four steps:
1 – Nutrition Assessment: gathering relevant data to identify nutrition problems. This is compared with established standards, evaluated, and documented.
2 – Nutrition Diagnosis: identifying any problem or risk of problem that is treated by a dietetics professional, e.g., a Registered Dietitian. This is distinct from a medical diagnosis, which is not directly treated by a dietetics professional. In one example provided by ADA, the medical diagnosis may be type 2 diabetes, while a nutrition diagnosis may be “undesirable overweight status” or “excessive carbohydrate intake”. A nutrition diagnosis has three parts: Problem, Etiology (causes), and Signs/Symptoms. These are represented by the acronym, PES, and all three are closely related.
3 – Nutrition Intervention: a set of activities that address the problem. The two parts of this step are planning the intervention and implementing the intervention.
4 – Nutrition Monitoring and Evaluation: measuring status at planned points in time and comparing findings with previous information to develop an evaluation. The ADA emphasizes this step is “more than just ‘watching’ what is happening; it requires an active commitment to measuring and recording the appropriate outcome indicators (markers) relevant to the nutrition diagnosis and intervention strategies.”
Some aspects of the ADA nutrition care process are still under development, and others may be refined in coming months. So far, however, the ADA Standardized Language Task Force has developed language to be used in conjunction with these areas:
- Nutrition diagnoses (Step 2 of the nutrition care process)
- Nutrition interventions (Step 3 of the nutrition care process)
Standardized Language: Nutrition Diagnoses
The ADA has identified 62 nutrition diagnoses, and each diagnosis has a code. The diagnoses fall into three groups—those related to:
- Intake (code NI), describing problems involving intake of energy, nutrients, fluids, etc. A few examples of problems in this category are: excessive energy intake, increased nutrient needs, or inadequate fluid intake.
- Clinical (code NC), describing problems associated with medical or physical conditions. Examples: swallowing difficulty, involuntary weight loss.
- Behavioral-Environmental (code NB), describing problems involving a client’s knowledge, attitudes/beliefs, physical environment, access to food, and food safety. Examples include: self-feeding difficulty, undesirable food choices.
Standardized Language – Nutrition Interventions
Nutrition Intervention terminology relates to the four classes of interventions defined by the ADA:
- Food and/or Nutrient Delivery (code ND): describes an individualized approach to providing food and nutrients.
- Nutrition Education (code E): describes a formal process to impart knowledge and/or train a client so that the client can manage food choices to maintain or improve health. The ADA notes, “Nutrition education involves the transfer of knowledge, tailored to the specific knowledge deficit identified in the Problem-Etiology-Signs/Symptoms statement.”
- Nutrition Counseling (code C-1): describes a supportive process to establish goals and individualized action plans to foster responsibility for self-care. The ADA notes that this is different from nutrition education, because nutrition counseling “involves behavior and attitude change, focused on the underlying behavioral and environmental etiologies….”
- Coordination of Nutrition Care (code RC): describes coordination of nutrition care with other healthcare providers.
For documenting nutrition care, the ADA recognizes a variety of formats, including the SOAP and narrative formats. In addition, it is offering new formats called Assessment, Diagnosis, and Intervention (ADI) or a longer version of this model called Assessment, Diagnosis, Intervention, Monitoring, and Evaluation (ADIME). In these formats, information is documented as it falls under each of these sections.
The ADA emphasizes that having a standardized process is not the same thing as standardized care, or a single way of managing nutritional needs. However, it provides structure to how care is provided through a series of connected steps.
In addition, it is important to understand that standardization of the process and the language is distinct from role delineation (who does what). Roles are largely dictated by state licensure regulations (See the State Licensure Agency List on the DMA website: www.anfponline.org/Advocacy/state_licensure.shtml), as well as by institutional policies and procedures.
Facility policies and the direction of a Registered Dietitian are important for maintaining effective documentation in both medical records and care plans, because standardization helps to ensure that documentation is meeting all legal and regulatory requirements, while also supporting clear communications among members of the healthcare team.
Because Certified Dietary Managers who provide support in the area of clinical nutritional care are working under the direction of Registered Dietitians, it is important for CDMs to become familiar with evolving ADA standards for documentation. For more information, talk with the Registered Dietitian in your organization, and take a look at the ADA book entitled Nutrition Diagnosis and Intervention: Standardized Language for the Nutrition Care Process, 2007.
By Sue Grossbauer