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S&I Framework Nutrition & Diet Elements

S&I Framework Nutrition & Diet Elements. October 12, 2011. Nutrition & Diet Elements . Background of Nutrition Standards Use of Nutrition Data Elements Nutrition Terminology Submission to SNOMED-CT Additional Nutrition Standards Work Nutrition & Diet Data Elements In Detail

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S&I Framework Nutrition & Diet Elements

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  1. S&I Framework Nutrition & Diet Elements October 12, 2011

  2. Nutrition & Diet Elements • Background of Nutrition Standards • Use of Nutrition Data Elements • Nutrition Terminology Submission to SNOMED-CT • Additional Nutrition Standards Work • Nutrition & Diet Data Elements In Detail • A-B and C-D Data Elements & Nutrition Care

  3. Background Nutrition professionals practicing in all areas of healthcare including in-patient acute care, long term care, and outpatient/ambulatory care use the Nutrition Care Process (NCP) for identifying, planning for, and meeting nutritional needs of patients/clients. The Nutrition Care Process includes four steps: • Nutrition Assessment • Diagnosis • Intervention • Monitoring & Evaluation Each step in the Nutrition Care Process has a set of standardized terms published by the Academy for Nutrition and Dietetics (AND) as the International Dietetics & Nutrition Terminology (IDNT). Work is currently underway to submit these terms to SNOMED-CT. The narrative summary and underlying IDNT codes would represent the nutrition and diet data that should be included in clinical summaries, nutrition consult request summaries, as well as discharge summary and instructions.

  4. Nutrition Informatics Survey 2011 HIMSS Analytics Elements of ADA Nutrition Care Process Standardize Language in Use Use of ADA’s Nutrition Care Process Standardized Language has increased since this study was last conducted. At this time, approximately 61 percent of respondents reported that they use nutrition diagnostic terms. Not asked Not asked Not asked Which elements of the ADA’s Nutrition Care Process Standardized Language are you using at your primary worksite? (Only those who said “yes” to question 15).

  5. IDNT-to-SNOMED Project Summary • Total: 646 terms, 146 headings (792 spreadsheet lines) • 6% of terms already in SNOMED CT • 49 % of terms ready for SNOMED CT submission • 30% of headings ready for SNOMED CT submission • 41% of terms and 61% of headings still need review

  6. Additional Work • HL7 Nutrition and Diet Orders Domain Analysis Model The first informative ballot of was balloted in September 2011. The second round of the ballot is scheduled for January or May 2012. • HL7 Patient Care Allergy Project: • HL7: EHR Functional Profile in Nutrition: The testing phase will last approximately 18 months, followed by changes to the profile as determined by test implementers, and balloting as a normative standard in January 2013. • HL7Patient Care Pressure Ulcer Prevention Model: Inclusion of Nutrition Care in Prevention & Treatment • S&I Nursing Codes Mapping Sub-Work Group: IDNT mapped to existing TOC-CIM categories Additional Model Federal Health Information Model : model of healthcare data developed for federal agencies, the Veterans Administration; untested.

  7. Diet CIM Object Summary

  8. Nutrition Diagnosis

  9. Diet CIM Objects (In Detail)

  10. Nutrition Intervention

  11. Nutrition Intervention (Continued)

  12. Nutrition/Diet Order (Detail)

  13. Nutrition/Diet Order (Detail – Continued)

  14. Nutritional Supplement – (In Progress)

  15. Enteral Nutrition – (In Progress)

  16. Nutrition Care Provider

  17. Nutrition Monitoring & Evaluation

  18. Nutrition Data Elements & CIM “A-B” • Active Medication List (including vitamin/mineral, herbal supplements) • Active Problem List • Intolerances including Allergies (Food) • Goals (Nutrition Related) • Patient Instructions (Food Modification/Enteral/Parenteral) • Social History (Alcohol) • Vital Signs (Ht/Wt/BMI with Date Stamp)

  19. Nutrition Data Elements & CIM “C-D” • Anticipatory Guidance • Goals • Health Maintenance • Patient Self-Management • Physical Activity (? Possibility of “B”) • Social Determinants of Health • Instrumental Activities of Daily Living • Activities of Daily Living

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