FROM THE ACADEMY

Nutrition Care Process and Model Update:

Toward Realizing People-Centered Care and
Outcomes Management
William I. Swan, FAND; Angela Vivanti, DHSc, AdvAPD*; Nancy A. Hakel-Smith, PhD, RD; Brenda Hotson, MSc, RD‡;
Ylva Orrevall, PhD, RD§; Naomi Trostler, PhD, RD¶, FAND; Kay Beck Howarter, MS, RDN; Constantina Papoutsakis, PhD, RD

T
HE NUTRITION CARE PROCESS The NCPM is updated approximately and Evaluation (Figure 1). The four
(NCP) is a systematic method every 5 years, which aligns with other steps are divided into two compo-
that nutrition and dietetics Academy resources such as Evidence- nents: problem identification and
practitioners use to provide Based Nutrition Practice Guidelines.8 problem solving. This distinction is
nutrition care.1 In this article, nutrition This ensures that the NCPM reflects important for application purposes.
and dietetics practitioners or profes- current practice. Problem identification includes Nutri-
sionals; dietitians; dietitians- This article presents an expert tion Assessment and Reassessment
nutritionists; and dietetic technicians, consensus update review of the NCPM (Step 1), and Nutrition Diagnosis (Step
registered, are collectively referred to completed during the year 2013-2014 2). Problem solving includes Nutrition
as professionals. The Nutrition Care by the Nutrition Care Process and Ter- Intervention (Step 3), and Nutrition
Process Model (NCPM) describes the minology (NCPT) Committee (which Monitoring and Evaluation (Step 4). It
NCP by presenting the workflow of became the Nutrition Care Process has been helpful for new adopters to
professionals in diverse individual and Research Outcomes Committee in implement the NCP in two consecutive
population care delivery settings. 2015) and its international workgroup. phases where Phase 1 involves imple-
Implementation of the NCPM has been Twenty-four experts from around the mentation of problem identification,
associated with several advantages, world participated in a consensus- and Phase 2 involves the addition of
including use of a common framework building process for each component problem solving. Each step is impor-
for nutrition care and research, promo- of the NCPM. They considered com- tant to complete before advancing to
tion of critical thinking, more-focused ments submitted to the NCP website, the next step. In practice, as new in-
nutrition care documentation, increased feedback from translators and users, as formation becomes available, pro-
acknowledgement of the value of well as international information on fessionals revisit previous steps of the
nutrition care by other health care pro- health quality goals. The current NCPM NCP to reassess, update nutrition di-
fessionals, and improved application of update highlights three themes that agnoses, adapt interventions, and/or
evidence-based guidelines.2-5 Potential emerged as a result of the consensus modify goals and monitor outcomes.
target audiences for the NCPM include process: use of concise language in the The NCPM (Figure 2) is depicted uni-
practitioners, educators and students, NCPM, promotion of professionals’ re- directionally where one progresses
professional credentialing agencies, sponsibility for outcomes manage- from Nutrition Assessment and Reas-
health system accrediting agencies, ment, and support for people-centered sessment to Nutrition Diagnosis, and so
health care funding organizations, care (PCC).9 Finally, experts recom- on; yet, in practice, the model is dy-
payers, and clients. mend associated actions to advance the namic and multidirectional to support
The Academy of Nutrition and Di- NCPM as the Academy embarks into its critical thinking and timely care. This is
etetics (Academy) adopted the NCP and second century initiatives toward a important in follow-up care of clients.
NCPM for use in the United States in world where all people thrive through As new information is collected, a
2003.1 Since then, international di- the transformative power of food and professional may revisit previous steps
etetics associations have supported nutrition. International input was an of the process to remove, add, or
adoption of the NCPM.6 The develop- important influence for improvement change nutrition diagnoses, adjust in-
ment history of the NCPM is described of the current revision. The information terventions, or modify goals and
in detail by Hammond and colleagues.7 in this article replaces previous infor- monitoring data. Monitoring and eval-
mation describing the NCPM. uation data from the prior client
*
AdvAPD¼Advanced Accredited Prac- interaction (or visit) is data that begins
tising Dietitian (Australia). ‡Certified in the reassessment of the subsequent
Canada. §Certified in Sweden. ¶Certi- BACKGROUND interaction. Hence, the model carries
fied in Israel.
The NCP is a roadmap and consists of over care from one interaction to the
2212-2672/Copyright ª 2017 by the four separate yet interconnected steps: next.
Academy of Nutrition and Dietetics. Nutrition Assessment and Reassess- The NCPM incorporates scientific
http://dx.doi.org/10.1016/j.jand.2017.07.015
ment, Nutrition Diagnosis, Nutrition evidence and aims to move pro-
Available online 5 October 2017
Intervention, and Nutrition Monitoring fessionals from experience-based to

ª 2017 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2003
FROM THE ACADEMY

Step 1: Nutrition Assessment and Reassessment

Definition and purpose Nutrition Assessment is a systematic approach to collect, classify, and synthesize important and
relevant data from clients (where “client” refers to individual and population). This step also
includes Reassessment, which additionally includes collection of new data, and comparing and re-
evaluating data from the previous interaction to the next. Nutrition Assessment is an ongoing,
dynamic process that involves initial data collection as well as continual reassessment and analysis
of the client’s status compared with accepted standards, recommendations, and/or goals
Data sources/tools for " Screening or referral form
assessment " Client interview
" Medical or health records
" Consultation with other caregivers, including family members
" Community-based surveys and focus groups
" Statistical reports, administrative data, and epidemiologic studies
Types of data collected " Food- and nutrition-related history
" Anthropometric measurements
" Biochemical data, medical tests, and procedures
" Nutrition-focused physical examination findings
" Client history
Nutrition assessment " Review data collected for factors that affect nutrition and health status
components " Cluster individual data to identify at least 1 nutrition diagnosis as described in diagnosis
reference sheets
" Identify accepted standards, recommendations, and/or goals by which data will be compared
Reassessment " Collect new data
components " Compare data with previous interaction/s:
" Compare the monitoring and evaluation outcomes/indicators documented in the previous
interaction to new data
" Evaluate if the client’s nutritional status has changed to demonstrate effectiveness of
intervention
" Evaluate the status of the Nutrition Diagnosis
" Evaluate whether the nutrition assessment data from the previous interaction need to be
reassessed or changed depending on the client’s status or situation
" Identify new nutrition assessment data to monitor and evaluate during the next interaction
Critical thinking " Determining important and relevant data to collect
" Determining the need for additional information
" Selecting assessment tools and procedures that match the situation
" Applying assessment tools in valid and reliable ways
" Validating the data
Determination for If upon completion of an initial Nutrition Assessment or Reassessment, it is determined that the
continuation of care problem cannot be modified by further nutrition care, discharge, or discontinuation from this
episode of nutrition care may be appropriate
Step 2. Nutrition Diagnosis
Definition and purpose Nutrition Diagnosis is a nutrition and dietetics professional’s identification and labeling of an existing
nutrition problem that the nutrition and dietetics professional is responsible for treating
Data sources/tools for Organized assessment data that is clustered for comparison with defining characteristics of
diagnosis suspected diagnoses as listed in diagnosis reference sheets

(continued on next page)

Figure 1. The 4 Steps of the Nutrition Care Process Model with distinguishing characteristics.

2004 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
 FROM THE ACADEMY

Nutrition Diagnosis The Nutrition Diagnosis is expressed using nutrition diagnostic terms and the etiologies, signs, and
components symptoms that have been identified in the reference sheets describing each diagnosis. There are
three distinct parts to a nutrition diagnostic statement:
1. The Nutrition Diagnosis describes alterations in a client’s status
2. Etiology is a factor gathered during the Nutrition Assessment that contributes to the exis-
tence or the maintenance of pathophysiological, psychosocial, situational, developmental,
cultural, and/or environmental problems
" The etiology is preceded by the words “related to”
" Identifying the etiology will lead to the selection of a nutrition intervention aimed at
resolving the underlying cause of the nutrition problem whenever possible
3. Signs/symptoms (defining characteristics)
The defining characteristics are a cluster of signs and symptoms that provide evidence that a
Nutrition Diagnosis exists
" The signs and symptoms are preceded by the words “as evidenced by”
" Signs are the observations of a trained professional
" Symptoms are changes reported by the client

Nutrition diagnostic A well-written nutrition diagnostic statement should be:

statement " Clear and concise;
" Specific to a client;
" Limited to a single client problem;
" Accurately related to 1 etiology; and
" Based on signs and symptoms from the assessment data

Critical thinking " Finding patterns and relationships among the data and possible causes
" Making inferences
" Stating the problem clearly and singularly
" Ruling in/ruling out specific diagnoses
" Identifying an etiology that may be resolved, lessened, or managed by the Intervention/s
" Identifying signs and symptoms that are measurable or their change may be tracked
" Prioritizing identified problems
Determination for Because the Nutrition Diagnosis names and describes the problem, the determination for problem
continuation of care solving follows the Nutrition Diagnosis step. If a professional does not identify a Nutrition
Diagnosis or the potential exists for a Nutrition Diagnosis to develop, a professional may
determine an appropriate method and interval for continuation of care
Step 3. Nutrition Intervention
Definition and purpose A Nutrition Intervention is a purposefully planned action(s) designed with the intent of changing a
nutrition-related behavior, risk factor, environmental condition, or aspect of health status.
Nutrition Intervention consists of two interrelated components: planning and intervention. The
Nutrition Intervention is typically directed toward resolving the nutrition diagnosis or the nutrition
etiology Less often, it is directed at relieving signs and symptoms
Data sources/tools for " The Academy of Nutrition and Dietetics’ Evidence-Based Nutrition Practice guidelines or other
Interventions evidence-based guidelines from professional organizations
" The Academy of Nutrition and Dietetics’ Evidence Analysis Library and other evidence such as
the Cochrane Library
" Current research literature
" Results of outcome management studies or quality improvement projects

(continued on next page)

Figure 1. (continued) The 4 Steps of the Nutrition Care Process Model with distinguishing characteristics.

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2005
FROM THE ACADEMY

Nutrition Intervention 1. Planning

components " Prioritize interventions based on urgency, influence, and available resources
" Write a nutrition prescription based on a client’s individualized recommended dietary
intake of energy and/or selected foods or nutrients based on current reference standards
and dietary guidelines and a client’s health condition and nutrition diagnosis
" Collaborate with the client to identify goals of the intervention for each diagnosis
" Select specific intervention strategies that are focused on the etiology of the problem
and that are known to be effective based on best current knowledge and evidence
" Define time and frequency or care, including intensity, duration, and follow-up
2. Implementation
" Collaborate with the client to carry out the plan of care
" Communicate the plan of nutrition care
" Modify the plan of care as needed
" Follow-up and verify that the plan is being implemented
" Revise strategies based on changes in condition or response to intervention

Critical thinking " Setting goals and prioritizing

" Defining the nutrition prescription or basic plan
" Making interdisciplinary connections
" Matching intervention strategies with client needs, nutrition diagnoses, and values
" Choosing from among alternatives to determine a course of action
" Specifying the time and frequency of care
Determination for If a client has met intervention goals or is not at this time able/ready to make needed changes, the
continuation of care professional may discharge the client from this episode of care as part of the planned intervention
Step 4. Nutrition Monitoring and Evaluation
Definition and purpose During the first interaction, appropriate outcomes/indicators are selected to be monitored and
evaluated at the next interaction. During subsequent interactions, these outcomes/indicators are
used to demonstrate the amount of progress made and whether goals or expected outcomes are
being met. Nutrition monitoring and evaluation identifies outcomes/indicators relevant to the
nutrition diagnosis and intervention plans and goals
Data sources/tools for Self-monitoring data or data from other records including forms, spreadsheets, and computer
Nutrition Monitoring programs
and Evaluation Anthropometric measurements, biochemical data, medical tests, and procedures
Client surveys, pretests, posttests, and/or questionnaires
Mail, telephone, and electronic media follow-up, such as e-mail
Types of outcomes " Nutrition-related history
measured " Anthropometric measurements
" Biochemical data, medical tests, and procedures
" Nutrition-focused physical findings
" Knowledge gained
" Behavior change
Nutrition Monitoring " In the first interaction: Select appropriate outcomes/indicators
and Evaluation " In subsequent interactions
components
This step includes three distinct and interrelated processes
1. Monitor progress
" Check client understanding and adherence with plan;
" Determine whether the intervention is being implemented as prescribed;

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Figure 1. (continued) The 4 Steps of the Nutrition Care Process Model with distinguishing characteristics.

2006 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
 FROM THE ACADEMY

" Provide evidence that the plan/intervention strategy is or is not changing client behavior
or status;
" Identify other positive or negative outcomes;
" Gather information indicating reasons for lack of progress; and
" Support conclusions with evidence
2. Measure outcomes/indicators
" Gather data for outcomes/indicators that are relevant to the nutrition diagnosis or signs
or symptoms, nutrition goals, medical diagnosis, outcomes, and quality management
goals
3. Evaluate outcomes/indicators
" Compare current findings with previous status, intervention goals, and reference
standards
Critical thinking Selecting appropriate outcomes/indicators
" Using appropriate reference standard for comparison
" Defining where client is in terms of expected outcomes
" Explaining variance from expected outcomes
" Determining factors that help or hinder progress
" Deciding between discharge or continued care

Determination for Based on the findings, the professional may actively continue care; or if nutrition care is complete or
continuation of care no further change is expected, discharge the client. If nutrition care continues, reassessment may
result in refinements to the diagnosis and intervention. If care does not continue, a client may still
be monitored for a change in status and re-enter nutrition care at a later date
Figure 1. (continued) The 4 Steps of the Nutrition Care Process Model with distinguishing characteristics.

evidence-based practice. The NCPM family and caregivers) and structures causes. Nutrition Assessment is initi-
strives to provide quality, consistent (eg, social service agencies and faith- ated from nutrition screening or client
practice and to achieve expected out- based organizations). In the Core, the referral. Nutrition Assessment is a
comes at all levels of career develop- word interacts describes the dynamic continuous process requiring initial
ment. If the NCPM is applied relationship between a professional data collection with continued reas-
consistently, quality of care and and a client in which PCC and client sessment and analysis of a client’s data
improved health outcomes should engagement contribute to treatment compared with accepted standards,
enhance recognition for professionals decisions, intervention strategies,10 or recommendations, and/or goals like
on multidisciplinary teams. Current environment changes. Interacts is a growth charts, dietary guidelines, and/
research demonstrates that it is broader and more inclusive word than or individual needs. Although pro-
possible to measure application of the relationship, which was used in the fessionals are familiar with performing
NCPM and demonstrate efficacy of the previous NCPM.11 Interacting encom- a Nutrition Assessment, the systematic
NCPM in practice.5 passes the care of populations and approach of Nutrition Assessment and
groups as well as individuals. For Reassessment coupled with standard-
NCPM example, a population survey is an ized terminology facilitates organized
interaction not a relationship. An documentation, encourages critical
Core interview is an interaction between a thinking, and supports communication,
The focus of the NCPM is a central Core client and a professional through collaboration, and quality care for cli-
that embraces the many and varied which a relationship can develop. Also, ents with nutrition-related problems.4
areas in which nutrition and dietetic an in-person or remote visit with cli- In this update, Nutrition Assessment
care is practiced. Consequently, pro- ent(s) is an interaction. and Reassessment is clarified further to
fessional interactions that influence describe specifically what a profes-
individuals and populations are recog- sional is expected to do (Figure 3). A
nized and incorporated into the model. Nutrition Assessment and critically thoughtful professional ac-
Populations refers to demographically Reassessment: Step 1 quires, analyzes, and interprets the
defined groups or otherwise identifi- Nutrition Assessment and Reassess- important and relevant data contrib-
able groups. Individuals and pop- ment is a systematic approach for col- uting to the potential nutrition-related
ulations are referred to as clients lecting, classifying, and synthesizing problem or problems. Critical thinking
throughout this article and client also data to describe nutritional status, tasks may vary with level of practice
includes supportive individuals (eg, related nutrition problems, and their (Figure 4).12

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2007
FROM THE ACADEMY

Figure 2. The Nutrition Care Process (NCP) Model.

The data collected and analyzed data of the previous interaction(s) information to develop or modify a
during this step direct professionals in inform Reassessment and the possibil- Nutrition Diagnosis that best fits the
the selection of a Nutrition Diagnosis. ity for changed nutrition diagnoses. present situation of a client.
New information that is collected dur- Thus, in a follow-up interaction, the
ing follow-up interactions (ie, in- Reassessment begins where Moni-
teractions that occur after the initial toring and Evaluation ended during the Nutrition Diagnosis: Step 2
one), and comparison of data between previous interaction. It should be From Nutrition Assessment data, a
interactions provide the basis for highlighted that Reassessment is not professional is able to determine
Reassessment, and the possibility for only comparing results from one whether there is a nutrition problem
changed or resolved Nutrition Di- interaction to the next to establish and label it as a Nutrition Diagnosis.
agnoses. As the nutrition intervention change/progress between interactions. Nutrition Diagnosis identifies and de-
unfolds during follow-up interactions, Reassessment is also an opportunity to scribes a specific problem or problems
the relevant Monitoring and Evaluation collect new important and relevant that can be resolved or improved

2008 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
 FROM THE ACADEMY

through Nutrition Intervention. A nutrition problem and the client’s whether Reassessment is necessary.
Nutrition Diagnosis (eg, inconsistent values and safety (Figure 4). Nutrition Standardized terms to assess the extent
carbohydrate intake)13 is different from intervention has two related planning of Nutrition Diagnosis resolution have
a medical diagnosis (eg, diabetes mel- phases. In the first phase, the profes- not been developed. But, as an
litus). As the client responds to Nutri- sional and client jointly determine example, the Academy of Nutrition and
tion Intervention, the Nutrition achievable and measurable goals. Dietetics Health Informatics Infra-
Diagnosis can improve or resolve. These goals are important to define the structure (ANDHII) currently uses the
Critical thinking is needed to prioritize time frame during which the nutrition following descriptors for resolution:
nutrition diagnoses for Nutrition problem is to be resolved, provide di- resolved, continued, and removed (for
Intervention. As shown in Figure 4, a rection to the plan, select and imple- more information on ANDHII, see the
variety of critical thinking tasks are ment interventions intended to achieve dedicated section in this article). A
important to develop the Nutrition the goals, provide criteria to measure Nutrition Diagnosis can be monitored
Diagnosis. For example, stating the results of intervention during Nutrition and evaluated at the end of a single
problem clearly and singularly is ex- Monitoring and Evaluation, and eval- visit. For example, learning assessment
pected to be carried out efficiently by a uate effectiveness of intervention and may be evaluated at the conclusion of a
novice professional. Other skills, such revise when indicated. The next phase nutrition education session.
as finding patterns, may be conquered is to determine the nutrition prescrip-
with greater experience. It is possible tion and interventions that will meet
and desirable that professionals of all the agreed upon goals. The specified Framing Rings
career stages are able to carry out activity to determine a nutrition pre- Two framing rings (outer and middle)
necessary critical thinking tasks.14 scription, a client’s recommended di- contextualize the four steps of the NCP
The Nutrition Diagnosis is commu- etary intake based on current reference (inner ring), and the Core (Figure 2).
nicated as an identify problem, deter- standards and dietary guidelines,13 is The outer ring represents the social
mine etiology/cause, and state signs new to the current revision of NCPM context of nutrition care. There are no
and symptoms (PES) statement. This (Figure 3). changes in the terms used to define the
PES statement is written with linking Interventions are a planned set of outer ring. However, the scope of these
words (ie, problem “related to” etiology specific behaviors or actions per- terms is broader. As defined in 2008,
“as evidenced by” signs and symp- formed, delegated, coordinated, or the outer ring represented the in-
toms). The NCPT, which is discussed recommended by a professional that fluences on how people received
more later in this article, provides a move a client toward a desired nutrition information.11 In the updated
standardized nutrition diagnostic ter- outcome. The chosen interventions NCPM, this ring also represents how
minology that defines nutrition prob- intend to alter or eliminate the etiology professionals engage their clients. Ex-
lems.13 It is important to review the to resolve the Nutrition Diagnosis. amples of client engagement in the
specific Nutrition Diagnosis definition With goals agreed upon, prescription outer ring include advocating public
to confirm that this is the most and interventions selected, action is policy within social systems or using a
appropriate Nutrition Diagnosis for the undertaken to implement Nutrition client portal within a health care sys-
situation. It is as important to review Intervention before proceeding to tem’s electronic health record for
the reference sheet of the Nutrition Monitoring and Evaluation. chronic care management.
Diagnosis from the NCPT to verify that The middle ring represents the
at least one indicator described in the required qualities and attributes that
respective reference sheet is present in Nutrition Monitoring and differentiate the nutrition and dietetics
the client’s assessment data. Next, a Evaluation: Step 4 professionals from other professions.11
professional determines the etiology or During Nutrition Monitoring and Eval- This is to emphasize that the nutrition
root cause of the nutrition problem. uation, a professional examines the and dietetics professionals contribute
The selection of interventions that timely results following implementa- the critical thinking, code of ethics, and
address the etiology are more likely to tion of Nutrition Interventions. For this evidence-based practice that are
provide desired nutrition care out- update, wording was clarified to unique to nutrition and dietetics sci-
comes. To finalize the PES statement, a incorporate key Nutrition Monitoring ence and practice. A significant change
professional selects signs and symp- and Evaluation practice actions within the middle ring was placing the
toms that can demonstrate resolution (Figures 2 and 3). These actions include word documentation in this ring after
or improvement in the nutritional selecting quality indicators derived removing the word document from
diagnosis as a result of Nutrition from best practices and evidence-based each step of the NCP. The expectation
Interventions. guidelines. Indicators use readily to document the NCP remains.
available data to provide a quantitative Although one may argue that commu-
measure for health professionals, or- nication, also included in this ring, im-
Nutrition Intervention: Step 3 ganizations, and planners aiming to plies the act of documentation, in some
When possible, Nutrition Intervention achieve improvement in the care and countries communication might be
is collaborative between a professional the processes by which client care is limited to verbal means and docu-
and a client. The professional plans the delivered.15 mentation may not be required or
Nutrition Intervention after prioritizing A professional monitors and evalu- might not be an allowed privilege for
Nutrition Diagnoses by critically ates the progress or resolution of the nutrition and dietetics professionals.
considering the severity of the Nutrition Diagnosis and determines The explicit inclusion of the concept of

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2009
FROM THE ACADEMY

Function The NCP Model The NCP Model

Review year 2008 2015
Standardized language " International Dietetics and Nutrition " Electronic
Terminology " NCP Terminology
" Print format (book) " Electronic format (web-based)
" Second edition (purple cover)
" Third edition (green cover)
" Fourth edition (yellow cover)
Nutrition Assessment and " Obtain/collect timely and appropriate data " Obtain/collect important and
Reassessment step " Analyze/interpret with evidence-based relevant data
(inner ring) standards " Analyze/interpret collected data
" Document
Nutrition Diagnosis step " Identify and label problem " Identify problem
(inner ring) " Determine cause/contributing risk factors " Determine etiology/cause
" Cluster signs and symptoms/defining " State signs and symptoms
characteristics
" Document
Nutrition Intervention " Plan nutrition intervention (set goals and " Determine intervention and
step (inner ring) determine a plan of action) prescription
" Implement nutrition intervention (care is " Formulate goals and determine
delivered and actions are carried out) action
" Document " Implement action
Nutrition Monitoring " Monitor progress " Select or identify quality indicators
and Evaluation step " Measure outcome indicators " Monitor and evaluate resolution of
(inner ring) " Evaluate outcomes diagnosis
" Document
Outcomes management " Monitor the success of the NCP " Research NCP
system implementation " Use aggregated data to conduct
" Evaluate influence with aggregate data research
" Identify and evaluate causes of less-than- " Conduct continuous quality
optimal performance and outcomes improvement
" Refine use of NCP " Calculate and report quality
indicators
Center circle (core) " Relationship between patient/client/group " Individual/population interacts with
and nutrition and dietetics practitioner nutrition and dietetics practitioner
Middle ring " Dietetics knowledge " Dietetics knowledge
" Skills and competencies " Skills and competencies
" Critical thinking " Critical thinking
" Collaboration " Collaboration
" Communication " Communication
" Evidence-based practice " Evidence-based practice
" Code of ethics " Code of ethics
" Documentation
Outer ring " Practice settings " Practice settings
" Health care systems " Health care systems
" Social systems " Social systems
" Economics " Economics

(continued on next page)

Figure 3. Comparison of functions in the Nutrition Care Process (NCP) Model.

2010 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
 FROM THE ACADEMY

Function The NCP Model The NCP Model

Screening and referral " Identify risk factors " Identify risk factors
system " Use appropriate tools and methods " Use appropriate tools and methods
" Improve interdisciplinary collaboration " Improve interdisciplinary
collaboration
Figure 3. (continued) Comparison of functions in the Nutrition Care Process (NCP) Model.

documentation in a framing ring was parts of the NCPM and its supporting already have or are at risk for nutrition-
deemed appropriate and necessary to structures and did not need designation related problems, who are appropriate
underline that documentation is a within the NCPM. Informatics tools may for nutrition care services, and who
requirement for professionals adopting not be available to all professionals and would benefit from participation in the
the NCPT internationally. This was professionals depend upon the outer NCP. The nutrition screening process
important given the range of practices ring for their availability. applies appropriate, valid, and reliable
or requirements internationally that screening tools and resources to iden-
vary from documentation in the health tify and recognize nutritional risk
record which is a legal requirement in SUPPORTING STRUCTURES factors.
some countries to no written docu-
mentation by dietitians because of Screening and Referral System
different levels of privileges. Docu- The Screening and Referral System is Outcomes Management System
mentation is a desirable source of data external to the rings of the NCP The Outcomes Management System is
for monitoring and evaluating care and because it may be carried out by col- a supporting structure outside the NCP
supporting the Outcomes Management laborators outside the nutrition and because it can be operated by members
System. dietetics profession. This supporting of various professions. As with Nutri-
The role and placement of nutrition system is often developed and tion Screening and Referral, the Out-
informatics in the framing rings was managed by professionals. The purpose comes Management System intends to
considered. The consensus was that of this system is to identify and refer be collaborative with leadership from
informatics provides useful tools for all those individuals and populations who professionals. In 2008, the Outcomes

Assessment& Re-assessmentb
N Novicea
Rule and tool dependent
Determining important and relevant data to collect – Ca
Determining the need for additional information – Ca
Lacks context and discretionary judgement Selecting assessment tools and procedures that match the
situation – Ca
B Beginnera
Starts to appreciate context Diagnosisb
Controlled learning Finding patterns and relationships among the data and
Treats aspects of work equally possible causes - Pa
Stating the problem clearly and singularly - Na
Nutrition Identifying an Etiology that may be resolved, lessened or
C Competenta
Encounters novel care managed by the Intervention/s - Ca
Begins to ID important vs unimportant data Identifying signs and symptoms that are measurable or their
Selects rules and tools appropriate to task Care change may be tracked - Ba
Prioritizing identified problems - Pa

P Proficienta
Organized thought patterns Process
Interventionb
Setting goals and prioritizing - Pa
Innovation, Prioritization Defining the nutrition prescription or basic plan - Na
Situational discrimination Making interdisciplinary connections - Pa
Problem solving based on experience Matching intervention strategies with client needs, nutrition
diagnoses, and values - Ca
A Advanced Practice/Experta
Monitors performance
Choosing from among alternatives to determine a course of
action - Ca
Does not rely on rules and principles
Intuitive; Sees whole situation Monitoring & Evaluationb
Selecting appropriate outcomes/indicators - Aa
Using appropriate reference standard for comparison - Na
Explaining variance from expected outcomes – Aa
Deciding between discharge or continued care - Ca

Figure 4. Acquisition of Nutrition Care Process (NCP) critical thinking. aAdapted with permission from: Charney P, Peterson SJ.
Critical thinking skills in nutrition assessment and diagnosis. http://www.eatrightpro.org/resource/practice/position-and-practice-
papers/practice-papers/practice-paper-critical-thinking-skills-in-nutrition-assessment. Published November 2013. Accessed
February 16, 2017.12. bFor each NCP step, the stated critical thinking task is labeled with the career development stage by which
one should feel confident performing the task. ID¼identification.

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2011
FROM THE ACADEMY

Management System emphasized reporting of quality indicators pursued collection of terms focused on public
improving and strengthening the by other national health systems. These health, and alternative synonyms
NCPM within the profession through activities support professionals’ ability for some behavior-related terms
the following four actions: monitor the to report quality measures and other considered harsh by the international
success of the NCP implementation, results from the Outcomes Manage- community. Documentation of the NCP
evaluate the influence [of the NCP] ment System to the framing rings. The using the NCPT creates data. The need
with aggregate data, identify and Outcomes Management System is to systematically collect these data and
analyze causes of less than optimal linked to the selection of quality in- research the NCP led to the design of
[NCP] performance and outcomes, and dicators during Nutrition Monitoring ANDHII, a web-based data registry.
refine the use of the NCP. These out- and Evaluation. Through the fully
comes management actions continue deployed Outcomes Management Sys-
and are combined in the updated tem, professionals influence the NCP ANDHII
model as Research NCP (Figure 2 and environment defined by the framing ANDHII is a data aggregation platform
Figure 3). rings. designed to collect data generated by
The updated NCPM challenges pro- the application of the NCP. The plat-
fessionals to demonstrate the form has three functions: Smart Visits
improved nutritional health of clients NCPT that enable data entry; Dietetics Out-
through participation in research and A terminology that describes the NCP is comes Registry that generates reports
quality improvement activities. Aggre- necessary to document the delivery using the aggregated data and support
gated data continue to be the founda- and study of nutrition care. Creation of comparative effectiveness studies; and
tion of NCP research. Infrastructure to the NCPT is a contemporaneous Nutrition Research Informatics, which
aggregate and manage data from the endeavor with the development of the facilitates data collection and manage-
NCP did not exist in 2008. An example NCP. Terminology work began in ment for quality improvement and
of this new infrastructure is the AND- 2003,18 and a terminology to support research projects. The structure of
HII.16 ANDHII makes possible the new the NCP was published as a printed ANDHII is the NCP with data being
activity, “Use aggregated data to manual in 2009: International Dietetics derived from NCPT.
conduct research.” This wording places and Nutrition Terminology Reference Data aggregation schemes abound in
Outcomes Management in the center of Manual: Standard Language for the health care. Data are routinely sub-
research priorities, which is necessary Nutrition Care Process.19 In 2014, Inter- mitted to health information ex-
to drive improvements at the organi- national Dietetics and Nutrition Ter- changes, accreditation agencies, payers,
zation and health systems levels.17 The minology was converted to an and government departments and
implication is that all professionals electronic database, called the eNCPT, ministries. Examples include metrics
when using the NCP become research as the management of an expanding required by The Joint Commission
participants as data contributors. Out- terminology (Figure 3) exceeded the concerning patient safety or informa-
comes Management is no longer a capabilities of a printed manual. eNCPT tion about 30-day readmissions
function reserved for those knowl- is currently translated from US English requested by the Centers for Medicare
edgeable in research design, data pro- into Swedish, German (Swiss), French and Medicaid Services.
cessing, and statistical analysis; rather, (Canadian), Norwegian, and Danish. At As with any electronic platform, the
it becomes an integral, collaborative the time of this writing, Chinese Academy continuously works to
activity for all professionals. (Simplified), Chinese (Mandarin), Por- improve ANDHII’s usability and func-
Outcomes research not only includes tuguese (Brazilian), and Spanish tionality to meet technologic, legisla-
NCP research to benefit professional (Mexican) translations are in progress. tive, and international needs. There is
development and practice, but also NCPT can be used to document potential for international use of AND-
aims to show the beneficial effect of nutrition care in any medium, but it is HII, although associated costs, trans-
the NCP on the health of clients.5 To fundamental when documenting in an lation, and varying research ethics
this end, two new activities are incor- electronic health record. In 2011, work regulations will need to be addressed.
porated into the Outcomes Manage- began to map and model the NCPT into ANDHII has been used to explore the
ment System of this updated NCPM. international medical terminology feasibility of validating malnutrition
First, “Conduct continuous quality standards. Mapping and modeling are diagnostic criteria by aggregating data
improvement” applies to improving essential for NCPT to be included in the from the United States and Australia.20
the model and care delivery as pro- document architecture for certified US ANDHII has also been used to investi-
fessionals participate in a learning or- electronic health records. These termi- gate the influence of evidence-based
ganization. The second activity, nologies have also been adopted in nutrition practice guidelines for the
“Calculate and report quality in- other countries. Mapping and prevention of diabetes on both practice
dicators,” supports the Academy’s modeling are continuous processes patterns and patient outcomes.5,21,22
engagement to promote the reporting because new terms are regularly being These studies have demonstrated the
of malnutrition quality measures added to the NCPT. Recent additions potential of incorporating tools such as
within the US health care system, include terms describing findings of ANDHII into practice. With the avail-
(http://www.eatrightpro.org/resource/ the Nutrition Focused Physical Exami- ability of ANDHII, the Outcomes Man-
practice/quality-management/quality- nation, terms resulting from moving agement System can be integrated into
improvement/malnutrition-quality- Malnutrition Disorders into the clinical practice much like the process of
improvement-initiative), and the domain of Nutrition Diagnosis, a learning to write a Nutrition Diagnosis.

2012 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12
 FROM THE ACADEMY

LOOKING AHEAD " support the NCP in diverse following implementation across a state-
wide health-care system. Nutr Diet.
This article describes the current NCPM practice cultures;
2015;72(3):222-231.
update and compares and contrasts it " determine economic value of
5. Thompson KL, Davidson P, Swan WI, et al.
with the 2008 version of the model.11 dietitian/nutritionist inter- Nutrition care process chains: The
Themes that emerged were concise ventions with clients; and “missing link” between research and
" continue international evidence-based practice. J Acad Nutr Diet.
language to promote translation, 2015;115(9):1491-1498.
dissemination and adoption of NCP, collaborations.
6. International Confederation of Dietetic
promotion of professional-driven out- Associations. “Dietetics around the
comes management with the emer- World: The Newsletter of the ICDA.”
Continuous Training Focused on 2011;18(2):2.
gence of smartphone applications and Practice Area and Professional’s 7. Hammond MI, Myers EF, Trostler N.
web-based data aggregation tools, and Career Development Stage Nutrition Care Process and Model: An
embracing PCC.9 Further, the article academic and practice odyssey. J Acad
describes how the NCPM is supported " Adopt NCPM to all stages of Nutr Diet. 2014;114(12):1879-1894.
by its standardized terminology, NCPT, career development, novice 8. Papoutsakis C, Moloney L, Sinley RC,
and outlines ongoing integration of through expert; Acosta A, Handu D, Steiber AL. Academy
of Nutrition and Dietetics methodology
NCPM/NCPT into an innovative out- " use NCPM as a framework for all for developing evidence-based nutrition
comes management platform.16 practice areas, including public practice guidelines. J Acad Nutr Diet.
The NCP and NCPM will continue to health, health promotion, and 2016;117(5):794-804.
undergo evaluation and updating. The disease prevention; 9. World Health Organization. People Cen-
study NCPM as an effective tool tred Care in Low- and Middle-Income
supporting NCPT will require refine- "
Countries—Meeting Report. Geneva,
ment to sustain the reporting of quality for educating professionals in Switzerland: World Health Organization;
measures and outcomes. Over the 14 science-based practice; and 2010.
years of the NCPM’s adoption, the NCP " train professionals to effectively 10. Sladdin I, Ball L, Bull C, Chaboyer W. Pa-
community has been growing and and efficiently use PCC resources tient-centred care to improve dietetic
practice: An integrative review. J Hum
actively contributes to the global up- and techniques. Nutr Diet. 2017;30(4):453-470.
take, improvement, and research of the 11. Nutrition Care Process and Model part I:
NCP.4-6,23-30 The NCPM has evolved What Professionals Can Do The 2008 update. J Am Diet Assoc.
with practice from a professional- 2008;108(7):1113-1117.
defined care delivery system to a PCC " Participate in the future and 12. Charney P, Peterson SJ. Practice Paper of
the Academy of Nutrition and Dietetics:
interaction. The NCPM progresses from share your plans at ncp@
Critical thinking skills in nutrition
learning to write nutrition diagnoses to eatright.org. assessment and diagnosis. J Acad Nutr
routinely entering outcomes of care " Contribute data to ANDHII to Diet. 2013;113(11):1545.
using a data aggregation tool. The NCP support outcomes research. 13. Academy of Nutrition and Dietetics.
is evolving to become the international " Collaborate in a translation of Nutrition Terminology Reference Manual
(eNCPT): Dietetics Language for Nutrition
standard for nutrition and dietetics NCP and NCPT. Care. Chicago, IL: Academy of Nutrition
care delivery. To foster this maturation, " Pursue continuing education and Dietetics; 2016.
three areas of focus are recommended: focused on quality indicators. 14. Shiner R, Tanner E, Collins C. RDN practice
" Advocate for the value that the level and application of the Nutrition Care
Creation of New Knowledge NCP brings to the health of Process. J Acad Nutr Diet. 2015;115(9):A25.

clients. 15. Mainz J. Defining and classifying clinical

" Support NCP-related research; indicators for quality improvement. Int J
" use aggregated data to study all
" Apply the NCP to create oppor- Qual Health Care. 2003;15(6):523-530.
steps of the NCP in a variety of tunities that integrate research,
16. Murphy WJ, Steiber AL. A new breed of
populations, practice cultures, professional development, and evidence and the tools to generate it:
and stages of professionals’ practice for innovation and Introducing ANDHII. J Acad Nutr Diet.
discovery. 2015;115(1):19-22.
career development; 17. Porter ME, Larsson S, Lee TH. Standard-
" validate expected plans of care izing patient outcomes measurement.
that link nutrition diagnoses References N Engl J Med. 2016;374(6):504-506.
1. Lacey K, Pritchett E. Nutrition Care Pro-
with specific interventions to cess and Model: ADA adopts road map to 18. Nutrition Care Process part II: Using the
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" investigate whether the NCP
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essential components of a conceptual
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" enhance and develop electronic, Assoc. 2004;104(12):1878-1884. 20. Hand RK, Murphy WJ, Field LB, et al.
digital standards, and structures 3. Memmer D. Implementation and practical Validation of the Academy/A.S.P.E.N.
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that accept NCP data. in the dialysis unit. J Ren Nutr. 2013;23(1): J Acad Nutr Diet. 2016;116(5):856-864.
65-73. 21. Hand RK, Abram JK. Sense of competence
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" Promote adoption of the NCP miliarity, knowledge and confidence with sults of a survey. J Acad Nutr Diet.
and translations of the NCPT; Nutrition Care Process Terminology 2016;116(4):695-705.

December 2017 Volume 117 Number 12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2013
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22. Murphy WJ, Yadrick MM, Hand RK. Vali- 25. Porter JM, Devine A, O’Sullivan TA. hemodialysis unit: Comparing paper vs
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AUTHOR INFORMATION
W. I. Swan is chair, Nutrition Care Process Outcomes Committee of the Academy of Nutrition and Dietetics, Taos, NM. A. Vivanti is chair, Nutrition
Care Process Outcomes International Workgroup of the Academy of Nutrition and Dietetics; a research and development dietitian, Department
of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Australia; and a senior lecturer, School of Human Movement and Nutrition
Studies, University of Queensland, Queensland, Australia. N. A. Hakel-Smith is a member of the Nutrition Care Process Outcomes Advisory
Workgroup of the Academy of Nutrition and Dietetics, and a manager, Clinical Nutrition Services, Bryan Medical Center, Lincoln, NE. B. Hotson is a
member of the Nutrition Care Process Outcomes Committee of the Academy of Nutrition and Dietetics; a member of the Nutrition Care Process
Outcomes International Workgroup of the Academy of Nutrition and Dietetics; and a regional clinical manager-acute care, Nutrition & Food
Services, Winnipeg Regional Health Authority, Winnepeg, Manitoba, Canada. Y. Orrevall is a member of the Nutrition Care Process Outcomes
International Workgroup of the Academy of Nutrition and Dietetics; head of research and development, Education & Innovation, Function Area
Clinical Nutrition, Karolinska University Hospital, Stockholm, Sweden; and is in the Department of Learning, Informatics, Management, and Ethics,
Karolinska Instutet, Stockholm, Sweden. N. Trostler is a member of the Nutrition Care Process Outcomes Committee of the Academy of Nutrition
and Dietetics; a member of the Nutrition Care Process Outcomes International Workgroup of the Academy of Nutrition and Dietetics; and a
retired professor, Faculty of Agriculture, Food, and Environmental Sciences, Hebrew University of Jerusalem, Rehovot, Israel. K. Beck Howarter is
principal, Ms. Nutrient Food and Nutrition Consulting Services, Evanston, IL; at the time of the study, she was director, Nutrition Care Process,
Research International Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL. C. Papoutsakis is director, Nutrition Care Process,
Research International Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL; at the time of the study, she was member of the
Nutrition Care Process Outcomes International Workgroup of the Academy of Nutrition and Dietetics, Chicago, IL.
Address correspondence to: Constantina Papoutsakis, PhD, RD, Academy of Nutrition and Dietetics, 120 S Riverside Plaza, Suite 2190, Chicago,
IL 60606. E-mail: cpapoutsakis@eatright.org
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
The Academy is the source of funding for the present Nutrition Care Process Model update. The authors and experts who conducted the
Nutrition Care Process Model update had complete autonomy during all stages of the update and writing of the present manuscript.
ACKNOWLEDGEMENTS
The authors thank those additional members of the Nutrition Care Process and Terminology Committee Research (NCP/T) Committee and the
NCP/T International Workgroup who served during 2013-2014 (Terry Brown, MBA, MPH, RD, LD, CNSC; Joyce Buhler, RDN, CDE, CD; Elizabeth
Copes, RDN, LD, CNSC; Ingrid Darnley, Maree Ferguson, PhD, MBA, AdvAPD, RD; Margaret Garner, MS, RD, LD; Debra Geary Hook, MPH, RD, CNSD,
CHES; Sue Kellie, MSc, FBDA; Yen Peng Lim, MHSc (Aust), PhD, ADS (Accredited Dietitian Singapore); Elisabet Rothenberg, PhD, RD; Carolyn Silzle,
MBA, MS, RD, LD; Christina Sollenberg, MSc, RD; Lyn Lloyd, RD; Maggie Gilligan, RD, CSG; Paula-Ritter-Gooder, PhD, RD, CSG, LMNT; Camela Rising,
MS, RDN, LDN; Lorraine Witherspoon, PhD, RD; and Jennifer A. Wooley, MS, RD, CNSC); and Academy of Nutrition and Dietetics staff members
Alison Steiber, PhD, RDN (chief science officer), Katie Gustafson (research assistant), and Robert Voss (NCP manager).

2014 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2017 Volume 117 Number 12