By the end of this read you will be able to Master The Nutrition Care Process (NCP)! I’ll give you real nutrition care process examples of how to work through the NCP and become an expert in no time! You’ll pass your documentation audits easily – Surveyors & Auditors will no longer scare you.
You’ve got this!
Now let’s dive in!
What is the Nutrition Care Process?
The Nutrition Care Process (NCP) simply put is a step-by-step approach for Registered Dietitians to treat patients.
It’s been around since 2003 and hopefully all interns are getting extensive education from their Dietitian mentor.
I recommend getting a copy of the nutrition care process terminology pdf if you don’t have one already. You need a copy because you need to see the nutrition diagnostic terminology! If you don’t have a copy you can google it and find some smaller versions for free.
Nutrition Care Process Steps:
Nutrition Assessment
Nutrition Diagnosis
Nutrition Interventions
Nutrition Monitoring & Evaluation
This allows for Dietitians to follow an easy framework of what comes next in your NCP.
The tough part comes up when trying to come up with a nutrition diagnosis. If you struggle with trying to diagnose, read this article, to find some great sample nutrition diagnosis!
The purpose of the NCP is to establish a nutrition care plan for your patient. Just follow the easy nutrition care process steps and then we’ll cover how to build a nutrition care plan.
Keep reading for help on how to implement the framework.
What is the ADIME Format/Charting?
ADIME is a form of charting, a really EASY way for RD’s to chart. It lays out our NCP perfectly.
Notice that those are exactly our nutrition care process steps?
In each section, you simply write what your NCP notes are for each.
How do you conduct a Nutrition Care Process?
Your NCP is always going to start with:
Step 1 – Perform a full nutrition assessment.
If you want an example of a full nutrition assessment, check out this case study here.
Let’s take it step-by-step though, if you go one step at a time you won’t get too overwhelmed.
Now don’t expect this process to be perfectly straight forward, we are still dealing with humans. You will adjust and readjust your interventions and care plan as new nutrition assessment data happens.
For example you may put in place an intervention such as Ensure twice daily to prevent weight loss. Then you find out that your patient hates Ensure…Curveball! Time to adapt and find another oral nutrition supplement that your patient will actually drink.
The purpose of the nutrition assessment is to find the nutrition problem (if there is one!). Don’t come up with a nutrition problem or nutrition diagnosis if it isn’t there.
In your nutrition assessment – collect all the data you need to make a conclusion if there is a nutrition diagnosis. If you want the BEST nutrition assessment form, click here. This nutrition assessment form has been designed for ALL Dietitian’s – with a built in SGA form! You can diagnose Malnutrition right in the form!
Once your nutrition assessment is complete, we’re going to move onto our nutrition diagnosis.
Step 2 – Nutrition Diagnosis
For this step, you are going to use the nutrition diagnostic terminology. I have an example below of common nutrition diagnoses that are used in clinical nutrition care.
This is not a comprehensive list of nutrition diagnoses – but it does give you a great idea of when to use them.
If you have 2-3 nutrition diagnoses on this list – diagnose your patient with Malnutrition! See this blog for more on PES statements.
From your nutrition diagnosis – you will now write your PES statement. I’ll be releasing WAY more info on how to write these on a future blog. But for now I’ll just give you some examples on how to develop a PES formula. The PES format is always the same.
Those are just a few examples – you may need to use nutrition diagnoses that are outside of that list. Make sure you check your nutrition diagnostic terminology sheets for other options!
Step 3 – Nutrition Intervention
Your nutrition intervention will target the nutrition diagnosis that you have found.
If you cannot change/target the nutrition diagnosis, you will work your intervention to reduce the signs & symptoms.
You also will reference the Standardised Nutrition Intervention Terminology sheet.
Depending on the area that you work in, the interventions will likely be in the Food and/or Nutrient Delivery area. If you work outpatient, you’ll likely be doing some type of nutrition education.
Ensure that your intervention is:
1) Realistic, 2) Patient approved, 3) Time sensitive.
Step 4 – Nutrition Monitoring and Evaluation
In the ADIME charting format this is 2 separate steps, but I’m going to combine it here as they go together very well!
Once you have a nutrition intervention down, you need to come up with a plan that includes:
1) How often am I going to monitor this patient?
2) What measurement tools will I use to assess if the intervention is working?
3) Set nutrition goals that you can evaluate against.
In your nutrition monitoring make sure that if your interventions aren’t having the desired effect – change them! Your nutrition monitoring and evaluation is going to be a non-linear process. Adapt to the changes you need to make.
What is the final step of the nutrition care process?
Evaluation and determining where to go with your patient is the last step. You need to evaluate whether this patient needs to be on your high risk patient tracker or if you can discharge them.
Remember you want to:
Monitor – Measure – Evaluate!
Once your patient is nutritionally stable – discharge them from your high risk tracking sheet. They will now be seen on a referral basis, or annual review.
If your patient needs to be followed up – for example if it’s for a pressure injury that you got a referral, set up a schedule. You may want to reassess your patient weekly, that would be your evaluation plan.
You Have Now Mastered The Nutrition Care Process!
It’s so important for Dietitian’s to provide consistency in care. You won’t see Doctors, Nurses, or Allied Healthcare Professionals, just come up with their own terminology. Especially for diagnoses. If we want to be taken seriously as a healthcare professional, we need to use our standardised nutrition terminology.
Don’t let your skills in this area slack. Keep up with constant education to be the most professional and educated RD out there. Whether you’re a new RD or have been practising for 20 years, it’s no reason to let your skills fall behind.
What should your next steps be?
Keep your eye out for education opportunities. Clearly if you’re reading this blog then you have a desire to keep up with your skills. This website will be starting to release education coursework to help keep your skills sharp and let you know the latest research out there!
If you want to see a full Nutrition Care Process Sample – Check out this blog post.
You can find a nutrition care process example so you can follow step-by-step.
Michelle
