NCP intervention, monitoring and evaluation, documentation

nutrition monitoring

preplanned review and measurement of selected nutrition care indicators of patient/client’s status relevant to the defined needs, nutrition diagnosis, nutrition intervention, and outcomes.

nutrition evaluation

the systematic comparison of current findings with the previous status, nutrition intervention goals, effectiveness of overall nutrition care, or a reference standard

Nutrition Care Outcomes

the results of nutrition care that are directly related to the nutrition diagnosis and the goals of the intervention plan

Nutrition Care Indicators

markers that can be measured and evaluated to determine effectiveness of nutrition care

nutrition intervention

Planned action = designed with the intent of changing a nutrition related behavior, risk factor, environmental condition or aspect of nutritional health status

Food & Nutrient Delivery

Nutrition Education

Nutrition Counseling

Coordination of Nutrition Care by a Nutrition Professional

Four Domains of Nutrition Intervention

Food and/or Nutrition Delivery

Individualized approach for food or nutrient provision

Nutrition Education

Instruct or train a patient in a skill

Impart knowledge

Nutrition Counseling

Collaborative counselor-patient relationship helps patients identify and solve their nutrition-related problems.

Assists individuals with establishing priorities and goals

Coordination of Nutrition Care

Consulting with and referring to other health professionals.

Coordination of nutrition care with other healthcare providers/institutions/dietitians with special skills

planning and implementation

STEPS IN NUTRITION INTERVENTION

planning

Formulate and determine plan of action

Implementation

Communicate the plan of nutrition care

Carry out the plan of nutrition care

Continue data collection and modify plan of care as needed.

NUTRITION PRESCRIPTION

The opening action

State the indiv’s recommended energy and nutrient intake based on current reference standards and dietary guidelines.

NUTRITION MONITORING & EVALUATION

Use selected outcome indicators (marker) that are relevant to the patient’s needs

Monitoring

review and measurement of the patient’s status at a scheduled follow-up

Evaluation

systematic comparison of current findings with previous status.

monitor progress

measure outcomes

evaluate measures

OUTCOMES MANAGEMENT SYSTEMS

Monitor Progress

Check patient/client/group understanding and compliance with plan

Determine if the intervention is being implemented as prescribed

Provide evidence that the plan/intervention strategy is or is not changing patient/client/group behavior or status

Measure Outcomes

Select outcome indicators that are relevant to the nutrition diagnosis or signs or symptoms, nutrition goals, medical diagnosis, and outcomes and quality management goals

Evaluate Measures

Compare current findings with previous status, intervention goals, or reference standards.

Direct Nutrition Outcomes

Clinical and Health Status Outcomes

Client centered Outcomes

Healthcare Utilization and Cost Outcomes

TYPES OF OUTCOMES

Direct Nutrition Outcomes

Behavior change, food or nutrient intake changes, improved nutrition status, knowledge gained.

Clinical & Health Status Outcomes

Lab values, weight, BP, risk factor profile changes, signs and symptoms, clinical status, infections

Client-centered Outcomes

Quality of life measures, satisfaction, self-eficacy, selfmanagement, and client’s functional ability

Healthcare Utilization and Cost Outcomes

Medication changes, special procedures, planned/unplanned clinic visits, preventable hospitalizations, length of hospitalization, or prevention/delay of nursing home admission

Food and Nutrition Related History Outcomes

Anthropometric Measurements Outcomes

Biochemical Data Medical Tests and Procedures Outcomes

Nutrition-Focused Physical Findings Outcomes

Categories in NME

Medical record

a permanent legal document that records the client’s history, assessment and diagnosis.

Identification information

Medical History

Medication Information

Family History

Treatment History

Medical Derivatives

Laboratory Results

Consent Forms

Financial Information

COMPONENTS OF MEDICAL RECORD

abbreviation

a shortened form of a written word or phrase.

may be used to save space and time, to avoid repetition of long words and phrases, or simply to conform to conventional usage.

Body Mass Index

BMI

Basal Metabolic Rate

BMR

Carbohydrate

CHO

Recommended Nutrient Intakes

RNI

Estimated Average Requirements

EAR

daily value

DV

upper limits

UL

Tolerable Upper Intake Level

TUIL

Acceptable Macronutrient Distribution Ranges

AMDR

Twice a day

BID

Three times a day

TID

Problem Oriented Medical Record

medical record approach that provides a quick and structured acquisition of the patient's history.

focuses on patient's problems, their evolution, and the relations between the clinical events.

Data Base

Complete Problem List

Initial Plans

Daily Progress Note

Final progress Note

Problem Oriented Medical Record Basic Components

DOCUMENTATION

Who, where, why, how

“if it is not written, consider it undone

SUBJECTIVE

Data from patient/caregiver, e.g. Food/Nutrition-Related History. Include diet recall/food allergies

OBJECTIVE

Physical evidence, e.g. Anthropometric Measures, Biochemical Data, Medical Tests and Procedures

ASSESSMENT

PES Statement: Problem, Etiology, Signs and Symptoms (overall nutrition status).

PLAN

Nutrition Prescription and Nutrition Intervention Details. Monitoring and Evaluation Plan.