The Nutrition Care Process or NCP is the process dietitians follow when documenting in the medical record. There are 4 steps to the Nutrition Care Process:

• Nutrition Assessment (A)
• Nutrition Diagnosis (D)
• Nutrition Intervention (I)
• Nutrition Monitoring and Evaluation (ME)

These steps guide your documentation. The note format is called ADIME.

In this episode, you'll learn:

• The difference between the Nutrition Diagnosis and Medical Diagnosis
• The steps of the Nutrition Care Process
• What a PES statement is and what goes into each part of the statement (hint: P = Problem, E = Etiology, S = Signs/Symptoms)
• 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.

And you'll learn a helpful tip on what to do when the Nutrition Diagnosis is hard to figure out.

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