Page 21 - Nutrition Counseling and Education Skills: A Guide for Professionals

The NCP uses the official international dietetics and nutrition terminology (eNCPT), a standardized set of
terms which is only available electronically. These terms are also used for documentation in the medical
record. Use in an electronic medical record, but not a paper record, requires permission from the Academy of
Nutrition and Dietetics since the language is protected by copyright.24 Adoption of a standardized eNCPT
language will enable electronic medical records to be searched for NCP and outcomes. This, in turn, will
provide evidence for health outcomes that can be attributed to nutrition intervention—and link to evidence-
based reimbursement for RDN counseling and education.

NCP is used by nutrition professionals when delivering quality nutrition care to patients, clients, and other
groups. There are four interrelated, sequential steps in a standardized process: (1) nutrition assessment, (2)
nutrition diagnosis, (3) nutrition intervention, and (4) nutrition monitoring and evaluation. Each step
provides information for the following step. However, if new information is obtained and a reassessment is
needed, previous steps may be revisited. NCP begins after the patient is referred by a health professional or
identified at possible nutritional risk (Figure 1-4).20

Figure 1-4 ■ The nutrition care process model.

Source: ©Academy of Nutrition and Dietetics. Reprinted with permission.

Step 1: Nutrition Assessment

The purpose of nutrition assessment is “to obtain, verify, and interpret data needed to identify nutrition-
related problems, their causes, and significance.”18 Nutrition-related data are obtained from patients/clients,
the medical record, and other family members and health professionals. There are five categories of data to
collect: (1) a food/nutrition-related history is often obtained by interviews; (2) anthropometric measurements,
such as height, weight, and body mass index (BMI); (3) results of biochemical data, medical tests, and
procedures in the medical record; (4) nutrition-focused physical findings, such as appetite and physical
appearance; and (5) a client personal history, some of which is in the medical record. Data are compared with
standards and interpreted.20

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