The Nutrition Care Process (NCP) is the standardized format dietitians use to document the nutrition care provided. The purpose of the Nutrition Care Process is to improve the quality of care and to standardize the process for providing nutrition care. There are 4 steps to the Nutrition Care Process:
Nutrition Assessment (A)
Nutrition Diagnosis (D)
Nutrition Intervention (I)
Nutrition Monitoring and Evaluation (ME)
These 4 steps of the Nutrition Care Process can be summarized with the acronym ADIME. In addition to using a standardized format, dietitians also use standardized language.
In this episode of the RD Exam Made Easy Podcast, you'll learn:
1) The difference between the Nutrition Diagnosis and Medical Diagnosis
2) The steps of the Nutrition Care Process
3) What a PES statement is and what goes into each part of the statement (hint: P = Problem, E = Etiology, S = Signs/Symptoms)
4) How your documentation should flow like a story. The Nutrition Diagnosis is connected to the Nutrition Intervention and the Nutrition Monitoring and Evaluation are the goals for the patient - you follow-up on these to assess the effectiveness of the intervention.
Here's a glance at this episode:
[3:50] The assessment is where all the important information about the patient is gathered and evaluated
[5:00] The NFPE is used to identify the presence of malnutrition
[7:52] The difference between the medical and nutrition diagnosis
[12:00] A breakdown of the Nutrition Diagnosis categories
[18:20] An example on how to work through a case with multiple problems and how to choose the most pertinent nutrition diagnosis
[22:00] A review of PES statements - the wording and format
[32:00] What to document when a patient doesn't have a nutrition problem or diagnosis
[33:12] A helpful tip to use when you're having a hard time figuring out the nutrition diagnosis
And I love making life a little easier. I offer a helpful tip at the end of the episode that I've used time and time again when I find the Nutrition Diagnosis is unclear. If you ever find yourself stuck at the Nutrition Diagnosis and don't know what to write, this tip will help you too.
Every group of dietitians I've worked with has leaned on each other when there's challenging cases. They ask for their ideas and feedback on how to address patients. That's what team work is all about. This is why there's an RD community. So lean on others for guidance and support when you need it.
Episode Transcript 
