The Nutrition Care Process Model (NCPM) serves as a roadmap for healthcare professionals engaged in providing nutrition and dietetics care. The NCP Model offers a systematic, evidence-based approach to assessing, diagnosing, planning, implementing, and evaluating nutrition and dietetics care. 

Structured around four sequential steps, the NCP Model guides nutrition and dietetics professionals through the process of delivering comprehensive nutrition and dietetics care:

1. Nutrition Assessment and Reassessment: This initial step involves gathering pertinent information about the individual's nutritional status, dietary habits, health history, and lifestyle factors. Regular reassessment ensures that care plans remain current and responsive to evolving needs.

2. Nutrition Diagnosis: Building upon the assessment findings, professionals identify nutrition-related problems and establish clear, actionable diagnoses. These diagnoses serve as the foundation for developing targeted interventions aimed at meeting specific nutritional needs and goals.

3. Nutrition Intervention: With diagnoses in hand, professionals collaborate with individuals and/or groups of people to develop and implement evidence-based nutrition interventions. These interventions may include a) customized approaches for food/nutrient provision such as dietary modifications, oral nutrition supplementation, and other forms of enteral or parenteral nutrition, b) nutrition education, c) nutrition counseling (frequently aiming to achieve behavior change among other objectives), and d) support services (such as coordination of nutrition and dietetics care) tailored to promote optimal health outcomes.

4. Nutrition Monitoring and Evaluation: Continuous monitoring and evaluation are integral to assessing the effectiveness of nutrition interventions and adjusting care plans as needed. By tracking progress and outcomes over time, healthcare professionals can ensure that individuals and/or groups of people receive ongoing support and achieve their nutrition-related goals.

Through its structured approach, the NCP Model enhances consistency, quality, and description of nutrition/dietetics care and related health outcomes. While care delivery remains individualized to meet the unique needs of those being served, the NCP Model provides a standardized framework for guiding professionals through the delivery process.

Reprinted from J Acad Nutr Diet. 2017 Dec, Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, Beck Howarter K, Papoutsakis C., Nutrition Care Process and Model Update: Toward Realizing People-Centered Care and Outcomes Management, Pages 2003-14, Copyright 2017, with permission from Elsevier. https://www.jandonline.org/

Nutrition Care Process Terminology (NCPT)

Complementing the NCPM is the Nutrition Care Process Terminology (NCPT), a standardized language developed to facilitate the documentation, communication, and exchange of nutrition and dietetics care data. Aligned with the NCPM, NCPT offers a comprehensive set of terms and codes that enable healthcare professionals to accurately capture and communicate related care information. 

The NCPT includes a set of terms for each step of the NCPM. Nutrition Assessment terms describe observed and measured data that provide evidence about nutrition-related problems or diagnoses. Nutrition Diagnosis terms describe the nutrition problem that nutrition and dietetics professionals are responsible for treating. Intervention terms describe planned actions aimed toward resolving nutrition problems. The Nutrition Assessment and Monitoring and Evaluation steps share, for the most part, the same terminology. Specifically, Nutrition Assessment terms that describe Client History are not included in the Monitoring and Evaluation terminology because nutrition interventions cannot change a client's history. When terms are used in the Monitoring and Evaluation step, they are used to describe outcomes or expected outcomes relevant to the Nutrition Diagnosis. NCP Terms for each step are organized by Domains. Domains are further organized into Classes and Subclasses. For example, the term Energy Intake falls under the Domain: Food/Nutrition-related History. (Detailed information on the current organization of NCPT and term definitions can be found atwww.ncpro.org (log in required)).

By employing standardized terminology and coding conventions outlined in NCPT, nutrition and dietetics professionals can ensure consistency, accuracy, and interoperability (automated data exchange) in documenting nutrition and dietetics care data across different electronic health record (EHR) systems. This standardized approach supports improved data quality, enhances communication between healthcare providers, and enables meaningful analysis and research on nutrition and dietetics care outcomes and health outcomes.

The development and adoption of the Nutrition Care Process Terminology (NCPT) have been the result of extensive international collaboration and usage, reflecting a global consensus on the need for standardized documentation and communication of nutrition and dietetics care data.

While vendors may initially question the investment required to integrate NCPT into electronic health record (EHR) systems, understanding its widespread acceptance and the benefits it offers can illuminate its value.

NCPT and SNOMED CT

Clinicians stand to benefit significantly from utilizing NCPT, regardless of whether they are already using SNOMED CT or not, as it provides a standardized language for documenting nutrition care data. The submission and modelling of NCPT in SNOMED CT further enhances NCPT's utility, facilitating seamless interoperability and enabling clinicians to leverage the SNOMED CT NCPT refset within the EHR. Even if clinicians are already using SNOMED CT, the SNOMED CT NCPT refset offers additional value by providing a curated set of concepts specifically tailored to document nutrition diagnosis within the Nutrition Care Process, streamlining documentation and ensuring consistency across practices.

This integration not only enhances the quality and efficiency of nutrition and dietetics care delivery but also supports informed clinical decision-making and research efforts aimed at improving patient outcomes. 

For systems who use NCPT as an interface terminology and pursuing to enable SNOMED CT, the Academy of Nutrition and Dietetics maintains mappings from NCPT to SNOMED CT (www.ncpro.org , log in required).

In summary, the NCP Model and NCPT represent foundational tools for guiding professionals in delivering evidence-based, personalized nutrition and dietetics care. By adopting tools like these, healthcare organizations can enhance the quality, consistency, and effectiveness of nutrition and dietetics care delivery, ultimately promoting better health outcomes for individuals and communities alike. Wide adoption also facilitates communication, data exchange and aggregation among health delivery systems, making the accumulation of big data and advanced analyses possible.