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Nutrition & Exercise in EHRs

Nutrition & Exercise in EHRs

At present, nutrition, diet and physical activity are not includes as core data for the Care Summary or Transitions of Care exchange in Stage 2 Meaningful Use. Following is a brief overview of standards, terminology and process harmonization by the Academy of Nutrition and Dietetics. This work is completed in expectation of supporting meaningful data exchange between patients, dietitians, providers and other care team members. It is important that “raw” clinical data based upon evidence-based care be included in all health information technology, so that patients may use and exchange structured nutrition data from consumer health technologies, and for nutrition to be included as part of the clinical decision support function of electronic health records (EHR).
The following information, with the exception of Health Level Seven (HL7) Diet/Nutrition Orders Project, have been included, by consensus, in the Standards & Interoperability Framework’s Transition of Care, Clinical Element Data Dictionary.
Nutrition Care Process (NCP)
The NCP is a systematic problem-solving method that food and nutrition professionals use to think critically and make decisions that address practice-related problems. The NCP provides a consistent structure and framework for food and nutrition professionals to use when delivering nutrition care and is designed for use with patients, clients, groups, and communities of all ages and conditions of health or disease. It includes four different processes:
1. NutritionAssessment
2. NutritionDiagnosis
3. NutritionIntervention
4. NutritionMonitoringandEvaluation