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Nutrition Care Process and Terminology

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Screening and Referral

Entry into the Nutrition Care Process (NCP) occurs when screening and/or referral occur. Clinical guidelines and policies in acute care settings advocate for routine screening for malnutrition risk. If a client is found at nutrition risk, the NCP begins. To support the screening of malnutrition, CDR has created a comprehensive list of malnutrition screening terms for adults and pediatrics, including definitions, references, and a list of available and validated translations for the tools.

Nutrition Care Process Overview

The Nutrition Care Process (NCP) is a framework for systematic problem-solving. It is used by nutrition and dietetics professionals to critically think and make decisions when providing safe, effective, timely, and equitable high quality nutrition care. The NCP consists of four distinct, interrelated steps: 

  • Nutrition Assessment and Reassessment
  • Nutrition Diagnosis
  • Nutrition Intervention
  • Nutrition Monitoring and Evaluation

Intended for use in any practice setting, the NCP is not a charting or documentation system. Use of the NCP and its terminology (NCPT) can lead to more efficient and effective care and communications, nutrition research, and greater recognition of nutrition in individual/population health and the role of credentialed nutrition and dietetics practitioners. The NCP facilitates a consistent approach to care and the NCPT provides a worldwide shared understanding and definitions of nutrition assessment/monitoring and evaluation, diagnostic, and intervention concepts.

Through its Nutrition Care Process and Terminology Committee and subcommittees, U.S. and international nutrition and dietetics professionals guide new implementation and education resources and terminology development and revisions as nutrition practice evolves. Helpful NCP infographics: Nutrition Assessment Critical Thinking, Nutrition Diagnosis Critical Thinking, Nutrition Intervention Critical Thinking, Nutrition Monitoring and Evaluation Critical Thinking.

Nutrition Care Process Terminology

To clearly document the impact of nutrition on client care, professionals need to have a terminology that is capable of capturing the specifics of the care they provide. Only when the profession can capture nutrition care in a consistent way can these activities be built or coded in electronic health records (EHRs), existing databases, and research projects to identify which elements of nutrition interventions are most important in achieving positive nutrition and health outcomes.

For nutrition care, a common process (the Nutrition Care Process) with a defined and agreed upon international terminology (NCPT) supports critical thinking, clearer and more focused nutrition care, more person-centered care, increased acknowledgement of the value of nutrition care by other health care professionals, and improved application of evidence‐ based guidelines. A free list of common structured terms are available to help meet the needs for the Global Malnutrition Composite Score, documentation in EHRs, and HL7 nutrition standards. Further, unique coding and identifiers for these common nutrition and dietetic terms enhance the ability to integrate the nutrition terminology in larger standardized health terminologies and standards for improved interoperability.

The NCPT is mapped (ie, linked to like concepts) and modeled (ie, computer processable) in two standardized health terminologies:

  • Logical Observation Identifier Names and Codes (LOINC®)—used by reference labs, healthcare providers, government agencies, insurance companies, software and device manufacturers.
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®)—the world's most comprehensive clinical healthcare terminology and accepted as a common global language in over 50 countries. In April 2024, SNOMED released a reference set of terms that are matched to NCPT problem (diagnosis) concepts. For more about SNOMED CT and the reference set, please see this article describing how this impacts nutrition and dietetic practice and these frequently asked questions.

Collaborations with both LOINC® and SNOMED International, to integrate Nutrition Care Process Terminology into these languages, ensures the availability of coded concepts for clearer and improved communication and data tracking in electronic health records.

The NCPT has been adopted, implemented and enhanced by U.S. and international professionals and organizations, as well as embraced by terminology and health information management standards. Visit the Academy's eNCPT for additional training and subscription information for using the terminology in Electronic Health Record (EHR) or Electronic Medical Record (EMR) systems.

Submissions for new and/or revised NCPT concepts are welcome. Please refer to the Editorial Guidance for NCPT for developing content for the nutrition care process.

Nutrition Care Process Model

The Nutrition Care Process and Model represents nutrition care within the context of nutrition and dietetics practice as a whole, health care, and health care systems. At the center is the interaction between the professional with the individual/population. Entry into the NCP occurs when screening and/or referral occur. NCP outcomes are data aggregated as part of a quality management system to continuously improve nutrition care. One (1) free continuing professional education unit (CPEU) is available for NCP and NCP terminology tutorials.

Use the NCP/NCPT Scorecard for nutrition care process improvement. This self-assessment tool identifies strengths and gaps in NCP/T in individual practice, systems, quality improvement, and/or practice evolution and continuity. Resources and FAQs to supplement the NCP/NCPT Scorecard may be helpful for its use.

The Nutrition Care Process Model (NCPM) illustrates a client-centered framework used by nutrition practitioners to deliver high-quality care, starting with screening and/or referral. At the model’s core is the relationship between the individual or population and the practitioner. The process includes four steps: 1) Nutrition Assessment, gathering data to identify nutrition-related problems; 2) Nutrition Diagnosis, defining nutrition issues based on assessment; 3) Nutrition Intervention, developing a personalized care plan; and 4) Nutrition Monitoring and Evaluation, tracking progress and adjusting interventions. The model is supported by practitioner attributes, such as the practitioner’s knowledge and skills, and the enabling environment, which includes policies and resources. Through outcomes management, practitioners can evaluate and strengthen health and nutrition care.
Resources to Demonstrate Quality Nutrition Care

NCP Infographics

 

NCP Resources

 

Standardized Health Terminologies

 

Additional Resources

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