Nutrition Care Process and Documentation Flashcards

Vocabulary practice flashcards covering Chapter 2: Overview of the Nutrition Care Process and Documentation.

Human biological factors

Factors that determine nutrient requirements as normal, increased, decreased, change in form, etc.

Lifestyle factors

Factors that determine food, physical activity, and related choices.

Food and nutrient factors

Factors that determine the type and amount of nutrients available for use by the body.

Environmental factors

External social and economic influences that impact consumption and lifestyle.

System factors

External influences that impact delivery and services.

Nutrition Care Process (NCP)

A systematic problem-solving method used by dietetics professionals to critically think and make decisions to address nutrition-related problems and provide safe, effective, high-quality nutrition care.

Standardized Nutrition Language

Uniform terminology used to describe professional practice, providing a common language for documentation and communication.

Content of care

A quality assurance component based on best evidence, verified science, standardized protocols, and guidelines.

Process of care

A quality assurance component that utilizes the Nutrition Care Process (NCP) framework.

Outcomes (Quality Assurance)

Systematic assessment of patient outcomes leading to higher quality of care.

NCP Model Central Core

The core of the Nutrition Care Process model, representing the relationship between the client and the dietetics professional, which is individualized and patient/client-centered.

Step 1: Nutrition Assessment

The step of the NCP involving obtaining, verifying, clustering, organizing, and evaluating patient data using reliable comparative standards.

Step 2: Nutrition Diagnosis

The step of the NCP that identifies and describes a specific nutrition problem for which nutrition-related activities provide the primary intervention, categorized into intake, clinical, behavioral-environmental, or nutrition situation.

PES Statement

A structured diagnostic statement formatted as: Problem (P) related to Etiology (E) as evidenced by Signs and Symptoms (S).

Problem (P)

A diagnostic label in a PES statement that describes in a general way an alteration in the client's nutritional status.

Etiology (E)

Factors related to the cause or existence of the nutrition problem in a PES statement.

Signs and Symptoms (S)

Defining characteristics obtained from subjective and objective nutrition assessment data in a PES statement.

Beliefs-Attitudes Etiology

A cause or contributing risk factor related to the conviction of the truth of some nutrition-related statement or phenomenon, or feelings/emotions toward that truth or phenomenon and activities.

Cultural Etiology

A cause or contributing risk factor related to the client's values, social norms, customs, religious beliefs, and/or political systems.

Knowledge Etiology

A cause or contributing risk factor impacting the level of understanding about food, nutrition and health, or nutrition-related information and guidelines.

Physical Function Etiology

A cause or contributing risk factor related to physical ability to engage in specific tasks; may be cognitive in nature.

Physiologic-Metabolic Etiology

A cause or contributing risk factor related to medical/health status that may have a nutritional impact.

Psychological Etiology

A cause or contributing risk factor related to a diagnosed or suspected mental health/psychological problem.

Social-Personal Etiology

A cause or contributing risk factor associated with the client's personal and/or social history.

Treatment Etiology

A cause or contributing risk factor related to medical or surgical treatment or other therapies and management or care.

Access Etiology

A cause or contributing risk factor that affects intake and the availability of safe, healthful food, water, and food/nutrition-related supplies.

Behavior Etiology

A cause or contributing risk factor related to actions which influence achievement of nutrition-related goals.

Step 3: Nutrition Intervention

The step of the NCP that involves prioritizing nutrition diagnoses, writing the nutrition prescription, setting goals, and selecting and implementing the nutrition intervention.

Step 4: Nutrition Monitoring and Evaluation

The step of the NCP that involves monitoring progress, measuring outcomes, and evaluating outcomes on a planned schedule.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

United States legislation that protects information about clients gathered by examination, observation, conversation, or treatment.

Figure 2.1 Relationship of the Nutrition Diagnosis to Other Steps of the NCP

Diagram illustrating how Step 2 (Nutrition Diagnosis) links to Assessment, Intervention, and Monitoring/Evaluation through specific chains (Evidence-Diagnosis, Diagnosis-Etiology, Etiology-Intervention, Intervention-Goal, and Diagnosis-Outcome links).

Figure 2.2 Overview of the Nutrition Care Process Standardized Language

Diagram showing the categorization of standardized terms into specific domains across the four steps of the Nutrition Care Process.

Nutrition Care Process Model Diagram

Graphic model illustrating the central core patient-dietitian relationship, surrounded by environmental factors and professional strengths, supported by Screening/Referral and Outcomes Management systems.