Standardized Language In Health Care

The nutrition care process provides a framework for individualized and high quality care 2,3,4 with the intention to guide nutrition professionals. Included in the nutrition care process, is the use of standardized language. Standardized language is important because it enables clear documentation of the impact and process of patient care.4 In addition, it also demonstrates the role of the dietetics profession while also ensuring that people can clearly articulate the nutrition problem and describe the interventions, goals and approaches that were executed.4 Standardized language enables a greater understanding of the connection between the nutrition problems, interventions and outcomes.4 ADIME is an acronym that stands for assessment, diagnosis,
The NCP is a standardized process-a consistent structure and frame work use to provide nutrition care.” 1 Before the formation of the NCP, the absence of standard nutrition language and accepted terminology, created a challenge for nutrition professionals to effectively communicate with each other and other health professionals in a consistent manner.1 Similarly, documentation of nutrition problems and interventions often used wide-ranging terminology.1 Likewise, nutrition care plans consisted of unclear statements such as “monitor weight or dietary intake” and “provide nutrition education.” 1 There was not a straightforward approach in classifying, measuring, and reporting on the results from the nutrition interventions used on patients to adequately analyze the efficacy of their nutrition care. 1Unspecified and unsystematic language also made it a challenge to obtain appropriate data necessary for research, education and reimbursement justification. 1 There was not standardized language to clearly explain and label nutrition problems. 1 Now, the standardized language is utilized in practice and as part of the NCP while providing a system for making nutrition care clear and uniformly comprehendible. 1Using standard terminology and process results in a decrease deviance of nutrition care and increased predictability of outcomes.1 By measuring client outcomes and the compliance with the accepted NCP, quality performance checks can be assessed.1 Thus, the NCP enhances high quality nutrition care provided. In addition, the NCP also allows for the patient goals, outcomes and evaluations to be clearly stated.1 The standardized language uses particular phrases and terms which are classified into domains and are assigned separate alphanumeric codes.1 The groups of standardized terms include: nutrition diagnosis, nutrition assessment and nutrition intervention.