Nutrition Care Process Form: What Dietitian’s Need to Include

Have you ever noticed that Doctors and Nurses typically chart at the end of the day all at once? They simply scribble notes on pads of paper and move on? I have translated this method using Nutrition Care Process Forms for Dietitian’s to use to help make their jobs easier.

Having a Nutrition Care Process form (NCP form) can save Dietitian’s not only time, but make their day go smoother. If you haven’t heard of NCP forms, let me explain what it is, and why you need it!

If you want your free Nutrition Care Process Form, you can either head to the Resource Section of the website, or simply click the image below to save!

What is the Nutrition Care Process?

I won’t go into too much detail here because as a Dietitian you likely already know all about it. If you don’t, go visit the Nutrition Care Process section of the website here. I’ll also add explain below if you have an NCP assessment form, what should be in it.

The Nutrition Care Process (NCP) is a systematic approach to providing high-quality nutrition care used by Registered Dietitian’s (RD’s). It was developed to ensure RD’s offer personalized, evidence-based care to their clients. 

The NCP consists of four critical steps: Assessment, Diagnosis, Intervention, and Monitoring/Evaluation. Each step is crucial for understanding and addressing the nutritional needs of individuals effectively.

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How to Use the Nutrition Care Process Form

Many RDs tell me that they just don’t have time to get everything done in a day that they need to, including charting. But if they have a good system in place, such as using this form, they will have time.

Here’s how to use the nutrition care process form:

  1. Print off a few of the NCP forms at the beginning of your work day.
  2. Develop your list of patients that you need to visit that day. Take that many NCP forms with you.
  3. For each patient you need to see simply fill in the date, patient name, room number, and a brief description of why you need to assess them.
  4. In each section of the form, fill in the NCP steps. Write brief notes, just enough information that you will be able to chart on it later.
  5. Carry the form in your binder and move onto the next patient assessment.
  6. Fill in all the NCP forms that you need with brief, bullet point information.
  7. When you’re all done seeing all the patients that you need to, simply go back and chart quickly using the information you gathered on each patient.

This process should cut down on the amount of time that you’re spending. It has worked for me, and it is a system that I use in my daily practice. By batching your work, you can save time and be more efficient.

Nurses frequently chart at the end of the day using little notes that they’ve written throughout their shift, RDs can do this too using these NCP forms!

Let’s take a closer look though at what pieces should make up your NCP!

two computers on a white desk with notebooks, a candle and flowers spread around.

Nutrition Assessment

The first step in the NCP is the Nutrition Assessment. This phase is critical as it lays the groundwork for the entire care plan. During this stage, RDs gather comprehensive data about the client.

If after reading this you don’t think your facility’s nutrition assessment form is comprehensive enough, check out this one that you can implement today! Clinical Nutrition Assessment Form.

Pieces to include in the nutrition assessment form:

  1. Food and/or Nutrition Related History
    1. Take note of food intake, food and nutrient administration, medication and complementary/alternative medicine supplement use, knowledge/beliefs/attitudes, behaviour, self feeding ability, physical activity and function.  Take note of preferences and dislikes.
  2. Anthropometric Measurement
    1. Body height or estimation, current body weight, usual body weight, body weight change, body mass index, body mass index range reference.  Note weight changes and reasons for it.
  3. Biochemical Data, Medical Tests, and Procedures
    1. Include relevant lab data (eg, electrolytes, blood glucose, vitamin d, b12, calcium) and tests (eg, recent surgeries, swallowing difficulties, GI issues).  You do not need to include everything, just what is relevant to their current nutrition status.
  4. Nutrition Focused Physical Exam
    1. Findings from a physical exam, interview, or the health record.  The most useful findings will be from the NFPE.  You should have a record written of your findings from the NFPE to have as a comparison for future nutrition assessments.
  5. Family/Social History
    1. Take note of family relationships, who you can relay nutrition information to, religious beliefs affecting food intake.
  6. Cognitive Function
    1. Note any cognitive impairments that affect nutrition intake.
  7. Symptoms Affecting Oral Intake
    1. Note any relevant medical diagnoses that are affecting nutrient intake (eg. constipation, diarrhea, anorexia, pain, dental issues, etc.).
  8. Functional Capacity
    1. Level of independence, ambulation, independently mobile, etc.
  9. Metabolic Requirements
    1. Only needed if patient has increased nutrient requirements based on increased nutrient needs as a nutrition diagnosis.
  10. Malnutrition Assessment Diagnosis
    1. Completed an Mini Nutritional Assessment (MNA) to determine if a Malnutrition diagnosis is appropriate.

This detailed collection of data allows RDs to identify potential nutrition-related issues and areas for intervention. 

For instance, if an assessment reveals a low dietary fiber intake, an RD can tailor dietary recommendations to increase whole grains, fruits, and vegetables. 

This personalized advice might include specific suggestions, like aiming for 25 grams of fiber per day, which could involve adding a cup of oatmeal (4 grams of fiber) for breakfast and a serving of lentils (15 grams of fiber) in a meal.

The Nutrition Assessment is not a one-time task but an ongoing process. RDs continuously update the client’s information to reflect changes in health status, dietary intake, and progress towards goals. This dynamic approach ensures that nutrition care remains relevant and effective, adapting to the client’s evolving needs.

By thoroughly understanding a client’s nutritional status, RDs can make informed decisions about the next steps in the Nutrition Care Process. This foundation is essential for developing a successful nutrition intervention plan, setting the stage for positive outcomes in the client’s health and well-being.

Nutrition Diagnosis: Identifying One

After gathering comprehensive data during the assessment phase, the next step in the Nutrition Care Process is the Nutrition Diagnosis. This stage involves analyzing the collected information to identify and label specific nutrition problems. The RD uses critical thinking to pinpoint the root causes of nutritional issues, which is crucial for effective intervention.

The nutrition diagnosis is articulated through a standardized language known as PES statements (Problem, Etiology, Signs/Symptoms). 

For example, an RD might diagnose a client with “Inadequate fiber intake (Problem) related to a limited consumption of fruits and vegetables and sources of fiber (Etiology) as evidenced by less than recommended servings per day and constipation (Signs/Symptoms).”

If you want help with your PES Statements, find the free guide; Perfecting Your PES Statements: Free RD Guide here.

This precise identification and labeling allow RDs to focus their interventions on the underlying causes of the nutrition problem. It also facilitates clear communication with clients and other healthcare professionals, ensuring a cohesive approach to care.

 The diagnosis guides the selection of targeted nutrition interventions tailored to address the specific issues identified.

The Nutrition Diagnosis is a critical step that bridges the gap between assessment and intervention. By clearly identifying and labeling nutrition problems, RDs can develop effective, evidence-based strategies to improve their clients’ health and well-being. 

Do you feel like you need to brush up on your nutrition diagnosis? Check out this free article: Nutrition Diagnosis Examples: Free Masterclass for Dietitians.

Nutrition Intervention: Tailored Strategies

Following the nutrition diagnosis, the next step in the Nutrition Care Process is Nutrition Intervention. This phase is where the RD puts their expertise into action, developing and implementing a customized plan to address the identified nutrition problems. 

The intervention is designed to target the root causes of the nutrition issues, aiming to alleviate symptoms and improve health outcomes.

RDs select interventions based on the best available evidence and the specific needs and preferences of the client. These interventions can range from dietary modifications and nutrition education to behavior change strategies and therapeutic diets.

 For instance, if a client has been diagnosed with inadequate fiber intake, an RD might prescribe increased fiber through whole grains, prune juice, and vegetables. 

The RD could provide practical tips, such as incorporating a high-fiber cereal for breakfast or adding beans to salads, aiming for a gradual increase to meet the recommended daily fiber intake of 25 to 38 grams.

Nutrition education plays a crucial role in interventions, empowering clients with the knowledge to make informed food choices. Though this can be a little less frequent when working in geriatric care due to cognitive impairments.  Nonetheless, education can still be provided and tailored to cognitive levels.

RDs might explain the benefits of fiber for digestive health and overall well-being, highlighting foods rich in fiber and how to incorporate them into meals and snacks. This educational component ensures clients understand the rationale behind the dietary recommendations, fostering adherence and long-term dietary changes.

Monitoring and adjusting the intervention is essential for success. RDs regularly evaluate the client’s progress towards their goals, making adjustments as needed. This might involve revising dietary recommendations based on the client’s feedback, addressing barriers to change, or refining goals to ensure they remain realistic and achievable.

This personalized approach underscores the value of the Nutrition Care Process in facilitating high-quality, evidence-based nutrition care.

Nutrition Monitoring and Evaluation: Measuring Progress 

The final step in the NCP is Nutrition Monitoring and Evaluation. This phase is crucial for assessing the effectiveness of the nutrition interventions and ensuring that the nutrition goals are being met. RDs use various methods to monitor progress and evaluate outcomes, allowing for timely adjustments to the care plan.

Monitoring involves regular check-ins with the patient to review dietary changes, challenges, and successes. 

For example, if the goal was to increase fiber intake, an RD might track the client’s daily fiber consumption and any related changes in health symptoms, such as improved digestion, reduced constipation, and increased levels of comfort. 

This continuous feedback loop enables RDs to provide support and encouragement, reinforcing positive changes and addressing any barriers to success.

Evaluation focuses on comparing the patient’s progress to the initial goals set during the assessment phase. This might include measuring changes in body weight, blood sugar levels, or other relevant health indicators. 

Another example could be a decrease in HbA1c levels in a client with diabetes would indicate successful management of blood sugar through dietary intervention. These measurable outcomes help to quantify the impact of nutrition care and demonstrate the value of personalized nutrition interventions.

Through regular monitoring and evaluation, RDs can ensure that their interventions are making a meaningful difference in their patients’ lives, adjusting strategies as needed to achieve optimal health outcomes.

Final Thoughts

The NCP can seem like a daunting process to ensure that you as the RD gets all the critical information needed. But with proper forms, you can ensure that you get it all. Simply having a quick form that you can scroll all the information down that you need, can help with charting later if you don’t currently have the time.

Don’t forget to check out the whole area of the website on the NCP, with lots of free helpful information! The Nutrition Care Process Website Section is here.

If you have any specific questions, feel free to drop them in the comments below!

If you want to learn more about the NCP, you can check out the Academy of Nutrition and Dietetics Website here.

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Michelle Saari is a Registered Dietitian based in Canada. She has a Master's Degree in Human Nutritional Sciences and is a passionate advocate for spreading easy to understand, reliable, and trustworthy nutrition information. She is currently a full time online entrepreneur with two nutrition focused websites.

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