Registered dietitian nutritionists have long provided medical nutrition therapy for individuals with health conditions such as diabetes through a framework of four steps collectively known as the Nutrition Care Process. Through an examination of a sample of deidentified patient chart notes entered into the Academy of Nutrition and Dietetics Health Informatics Infrastructure, or ANDHII, by RDNs providing MNT to patients with diabetes, the findings from this study demonstrate that when the signs and symptoms of a nutrition diagnosis in step 2 of the NCP are documented in the RDN’s assessment in step 1 of the NCP, the nutrition diagnosis is almost three times more likely to become resolved.
This connection between the information collected during the patient visit and subsequent documentation in both the assessment and diagnosis is one of several NCP linkages recently discovered as necessary components for both high-quality MNT and high-quality documentation.
These findings and recent similar research findings underscore the importance of RDNs understanding and including NCP linkages in care and documentation. Resolving nutrition diagnoses in patients with diabetes supports the reduction of both short-term and long-term risk factors associated with diabetes which can improve the status, longevity and quality of life in this patient population. Read the full article, “Documentation of the evidence-diagnosis link predicts nutrition diagnosis resolution in the Academy of Nutrition and Dietetics' diabetes mellitus registry study: A secondary analysis of Nutrition Care Process outcomes,” published in Frontiers in Nutrition.
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