Nutrition Care Process Model
Tutorials
Nutrition Care Process and Terminology Committee
Academy of Nutrition and Dietetics
Nutrition Care Process Terminology
2015 Edition
Nutrition Assessment:
Terms and Use
Module Objectives
By the end of this module, the participant will:
• Understand the organization of domains and
classes of the nutrition assessment terms.
• Understand the relevance and usage of the
terms within each domain and class.
Terms: Overview
Nutrition Assessment and Re-Assessment
• Obtaining, analyzing, and documenting data
• Terms are organized into five domains
• Within each domain terms are organized into
classes and sub-classes
• Each term is given an alpha-numeric term
number to help link placement of the term in the
term list and the corresponding reference sheet.
There is no need or reason to use this alpha-
numeric number in charting.
1
Domains, Classes, and Sub-Classes
Nutrition Assessment domains, classes, and sub-classes are:
Food –Nutrition Related History: data you would collect as a
part of the interview or written assessment (food record) from
the patient and includes:
• Food and nutrient intake
• Food and Nutrient Administration
• Medication and Complimentary/Alternative Medicine Use
• Knowledge, Beliefs, Attitudes
• Behavioral factors effecting achievement of nutrition-
related goals
• Factors Affecting Access to Food and Food/Nutrition-
Related Supplies
• Physical Activity and Function
• Nutrition-Related Patient/Client-Centered Measures
Domains, Classes, and Sub-Classes
Nutrition Assessment domains, classes, and sub-
classes are:
Anthropometric Measurements
• Height
• Weight
• Body Mass Index
• Growth pattern indices, percentile ranks
• Weight history
Domains, Classes, and Sub-Classes
Nutrition Assessment domains, classes, and
sub-classes are:
Biochemical Data, Medical Tests, and Procedures
• Laboratory Data, e.g., electrolytes, glucose
• Tests, e.g., gastric emptying time, resting
metabolic rate
2
Domains, Classes, and Sub-Classes
Nutrition Assessment domains, classes, and sub-
classes are:
Nutrition-Focused Physical Findings: findings from
observation and evaluation of body systems
• Muscle and sub-cutaneous fat wasting
• Oral health
• Suck, swallow, breathe ability
• Appetite
Domains, Classes, and Sub-Classes
Nutrition Assessment domains, classes, and sub-
classes are:
Client History
• Personal history including general information
such as age, gender, ethnicity
• Patient/Client/Family Medical History, including
disease states, conditions, illnesses
• Social History includes socioeconomic data,
housing, medical care support, involvement in
social groups
Examples
Review the Nutrition Assessment (and Monitoring and Evaluation)
Terminology Sheet to see the organization of terms.
[http://ncpt.webauthor.com/pubs/idnt-en/page-006]
An example of a term within a sub-class, class, and domain is:
• Food-Nutrition Related History (FH) (Domain)
• Food and Nutrient Intake (1) (Class) Composition and adequacy of food
and nutrient intake, meal and snack patterns, current and previous diets
and/or food modifications, and eating environment.
• Energy Intake (1.1) (Sub-Class) Total energy intake from all sources
including food, beverages, breastmilk/formula, supplements, and via
enteral and parenteral routes
• Total Energy Intake (FH-1.1.1.1) (Term) 10005 (the Academy’s
SNOMED Unique Identifier* for the term)
* assigned for data tracking purposes in electronic health records. For more
information, look under the “Resources” tab and open “The NCPT and
EHRs”
3
Comparative Standards
Comparative Standards are the terms used
by the RD, RDN, DTR for comparison of the
collected data to determine a nutrition
diagnosis (problem)
In Summary
Assessment terminology is organized in
domains, classes, and sub-classes.
Accurate use of the assessment
terminology is important for accuracy
throughout the Nutrition Care Process.
