Nelms_3e_ch13 - practice applications TOPICS OF...

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practice applications TOPICS OF PROFESSIONAL INTEREST Nutrition Care Process Part II: Using the International Dietetics and Nutrition Terminology to Document the Nutrition Care Process A regularly scheduled update of the Nutrition Care Process and Model (NCPM) was presented in Part I of this manuscript ( 1 ). Activi- ties of registered dietitians (RDs) within the four steps of the Nutrition Care Process and Model are described using the International Dietetics and Nutrition Terminology (IDNT) ( 2 ). This standardized language or con- trolled vocabulary is being developed to describe the unique functions of di- etetics in nutrition assessment, nutri- tion diagnosis, nutrition intervention, and nutrition monitoring and evalua- tion. The IDNT is designed to facili- tate clear and consistent descriptions of the services RDs provide both within and outside the profession. The NCPM and IDNT are comple- mentary tools. The NCPM is a prob- lem-solving model, while the IDNT pro- vides a standardized set of terms used to describe the results of each step of the model. The vision for these tools is not only to facilitate communication, but to enable researchers to more clearly describe the types of nutrition problems observed in patient popula- tions, the interventions provided, and the results of those interventions. These tools will also facilitate medical record documentation as the health care system moves to implement the federal mandate of an electronic health record for every American by 2014 ( 3 ). A single set of defined terms, the IDNT will facilitate including RD activities in not only electronic health records, but also in policies, procedures, rules, and legislation. The purpose of this article is to review how the standardized lan- guage is being developed and how it may be used to document care. BACKGROUND The IDNT was conceived as a con- trolled vocabulary, defined by the Na- tional Library of Medicine as a system of terms, involving definitions, hierar- chical structure, and cross-references, used to index and retrieve a body of literature in a bibliographic, factual, or other database ( 4 ). RDs are familiar with standardized languages such as the International Classification of Dis- eases (ICD-9/ICD-10) and the Common Procedural Terms (CPT) that are used extensively in health systems manage- ment ( 5,6 ). The American Medical As- sociation, which owns and licenses the CPT codes, has designated two terms for use by RDs ( 7 ). The nursing, phys- ical therapy, and occupational therapy professions have created controlled vo- cabularies or standardized languages that describe their unique functions ( 8- 10 ). Some of these vocabularies contain nutrition terms, but none of the terms adequately describe the breadth and depth of activities unique to the profes- sion of dietetics.
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