Nutrition and Dietetic Process Terminology
The BDA has approved the adoption, with adaptations, of the international Nutrition Care Process Terminology (NCPT) as the preferred standardised language (terminology) for use in electronic records.
The primary purpose of dietetic records is to record and communicate information about the dietetic intervention. Incomplete or disorganised notes can lead to poor care and allegations of incompetence; conversely structured records can improve care. The use of a systematic process and standard language facilitates standardised records and the sharing and secondary uses of the information held in the record.
Secondary uses include public health and research uses, service management and evaluation and individual professional audit and evaluation.
A standardised language is needed in dietetic practice to:
- facilitate clear communication within the profession, between professions and with service users
- share information across systems
- capture information safely and consistently for different purposes
- reduces the need for dietitians and services users to duplicate information
- reduce errors and improve record keeping
- facilitate audit, research and quality improvement
'SNOMED CT' clinical terminology has been adopted as the standard clinical terminology for the NHS in England and is likely to be used across the UK.
SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms), consists of comprehensive
scientifically validated content. It is the most comprehensive international terminology currently available and can be used across all care settings and all clinical domains. There are some nutrition and dietetic terms available and the BDA is working with colleagues across the UK and internationally to develop further content.
NCPT will be integrated into SNOMED CT to provide a UK focussed standardised language for use in dietetic records on paper and electronically.
The first tranche of UK focussed dietetic specific terms are now available. These diagnosis terms support dietitians to record their unique contribution to patient care. They are suitable for use in paper or electronic records and are available in SNOMED CT and CTV3 electronic terminologies. For further information on using the Process see the relevant pages. Materials including a presentation and case studies using the Process and diagnosis terms are here.
If you wish to discuss further please contact Sue Kellie email@example.com or tel 0121 2008080
If you would like to contribute to the discussion on the use of the Process and Diagnosis join the Discussion Forum