January, 2007

A Good-bye SOAP, Hello PESS — Nutrition Diagnosis and the New Process for Nutritional Care
By Carol M. Meerschaert, RD
Today’s Dietitian
Vol. 9 No. 1 P. 46

The ADA is washing its hands of SOAP notes and implementing a more standardized, evidence-based nutrition care process.

Jane Smith is admitted to your floor of the hospital. She is (at first glance, at least) 150 pounds overweight and has just been diagnosed with diabetes. Her physician writes the order “Dietitian to instruct patient on 1,200-calorie ADA (American Dietetic Association) diet.” You go see Mrs. Smith.

Before, when I was a clinical dietitian, I would review Mrs. Smith’s chart and her labs, interview her, talk to her nurse and the hospital’s discharge coordinator, and then instruct her on her diet and write a SOAP (subjective, objective, assessment, and plan) note. I thought I was doing a good job, but could I prove it? All clinical dietitians kept a log of every patient visited, and we had great data on the number of patient visits.

Those days are gone. No longer is healthcare about how busy you are or how many patients you move through the system. What the world wants to know is: Were you effective? Did you really solve any of Mrs. Smith’s nutritional problems?

Now imagine yourself in the near future, once the ADA Nutrition Care Process is fully implemented. The clinical dietitian will see Mrs. Smith, talk to her care providers, and perform a nutritional assessment. But when charting, he or she will write a nutritional diagnosis that includes a PESS (problem, etiology, signs, and symptoms) statement. This amazing dietitian will use standardized language that will allow him or her to later do a study tracking patient outcomes and prove to the powers that be just how effective he or she is at solving the patient’s nutritional problems.

Previewing the New Process
The PESS statement and nutrition diagnosis are part of the ADA Nutrition Care Process model adopted in 2003. This process is a “systematic problem-solving method that dietetics professionals use to think critically and make decisions to address nutrition-related problems and provide safe, effective, high-quality nutrition care.”1 The Nutrition Care Process consists of several steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation.

The purpose of creating and using a nutrition care process is to bring us further toward the ADA’s goal of increasing demand and utilization of ADA member services and empower members to compete successfully in a rapidly changing environment.2 When all dietetics professionals implement this process, there will be a consistent and standard way in which we all practice. That will make outcomes research much easier; we can then compare apples to apples and inadequate intake to inadequate intake. This research, in turn, can be used to prove the power of nutrition intervention and RD services so that someday, perhaps all of these services will be covered by insurance companies and government health programs such as Medicare and Medicaid.

Additionally, the Institute of Medicine says the quality of a provider’s care is measured by outcomes and by how well he or she adheres to a process.2,3 Dietitians need this nutrition care process and outcomes that can then be derived from the process to prove that we provide quality care. Healthcare is, like every other business, defined by outcomes. We must prove what we have done to help the patient. Dietitians should expect to be paid like everyone else—for what they do and what they accomplish, not who they are or their education level.

Nutritional assessment, the first step in this nutrition care process, is one with which every dietitian is familiar. Thankfully, that part remains the same. But nutrition diagnosis is a new skill to master. The nutrition diagnosis is “the identification and labeling that describes an actual occurrence, risk of, or potential for developing a nutritional problem that dietetics professionals are responsible for treating independently.”1 This is not to be confused with the patient’s medical diagnosis. “It is almost a misnomer to use the word diagnosis, as this is not a medical diagnosis,” says Douglas S. Kalman, PhD candidate, MS, RD, FACN, director of nutrition and applied clinical research at Miami Research Associates. “The term developed from the nursing care plan model, in which nurses create a nursing diagnosis and plan.”

According to the North American Nursing Diagnosis Association (NANDA) Web site (www.nanda.org), nursing diagnoses are part of a movement in nursing to standardize the terminology involved in patient care and include standard descriptions of diagnoses, interventions, and outcomes. The NANDA Web site states, “Nurses who support standardized terminology believe that it will help nursing become more scientific and evidence-based.” Evidence-based care is the future of healthcare, so like nurses, dietitians will also adopt the standardized terminology to prove that dietetics is evidence-based.

The medical diagnosis is created by the physician; the nutrition diagnosis is created by the dietitian. The medical diagnosis may or may not have much to do with what interventions the dietitian must implement to assist the patient. Let’s say, for example, that both Jane and Gary Smith have been diagnosed with diabetes. Jane is Gary’s mother, is overweight, and takes an oral agent for her diabetes. Gary is a 10-year-old, newly diagnosed, insulin-dependent person with diabetes. He lost 15 pounds in the last month and is now underweight. Your work with these two people is clearly different, even though their medical diagnosis is the same.

Another difference between medical and nutrition diagnoses is that we can make the nutrition diagnosis vanish. If the diagnosis is inadequate oral intake or excessive sodium intake, we can solve those problems, even if the medical diagnosis of cancer or hypertension remains.

The overall goal of this new method of practice is that dietitians create a nutrition care plan, just as nurses create a nursing care plan. Instead of charting general facts about the patient, the RD will chart what nutrition services will do for the patient. Based on his or her assessment, the dietitian will construct a nutrition diagnosis, written in the form of a highly structured statement. The statement is developed using PESS format that states the patient’s problem (diagnostic label), etiology (cause/contributing risk factors), and signs and symptoms (defining characteristics).

According to Lacey and Pritchett, a well-written Nutrition Diagnostic Statement should be2:

• clear and concise;

• specific and patient-centered;

• related to one client problem;

• related to one etiology; and

• based on reliable and accurate assessment data.

This concise problem statement, written in standardized language, will allow the practitioner to match the dietetics services provided to the problem and demonstrate that dietetics services solved the patient’s problem. An entire nutrition services team’s use of this method will allow the department to prove that medical nutrition therapy saves money and lives.

Writing the Nutrition Diagnosis
The first step is to write the problem (the P in PESS) part of the diagnosis, also known as the diagnostic label. The problem states how the patient deviates from the desired state. To write the problem, you must now use one of the approved nutrition diagnostic labels. A diagnostic label is really just a qualifier (an adjective) that describes the patient. Approved labels include altered, impaired, ineffective, increased or decreased, risk of, and acute or chronic.

So far, 62 nutrition diagnoses have been assigned labels and are classified under three “domains,” or broad categories.4 The domains are clinical, behavioral-environmental, and intake. See the “For Your Bookshelf” section for information on how to purchase the list from the ADA. Under each domain are several classes. For example, under the domain “clinical,” you find “weight balance.” The behavioral-environmental domain contains classes such as “knowledge and beliefs.” In the intake domain, you will find “caloric energy balance” and “oral or nutrition support intake.” The next level is the subclass. For example, under the class “nutrient balance,” you logically find “fat and cholesterol balance” and “protein balance.” Each term has a precise definition.

Each term also has an associated alpha-numeric code. This code will plug into electronic medical records (EMRs) and databases. Really, this is just another verse from the song you already sing with ICD-9 (International Classification of Diseases, Ninth Revision) or Diagnostic and Statistical Manual of Mental Disorders, fourth edition terms and codes.

Step two is the etiology (E in PESS). This is the step at which you state the cause and/or contributing risk factors. This is the link from the problem to the problem’s cause. These etiologies are factors contributing to the existence or maintenance of the problem you stated in step one. The etiology may be of a social, situational, physical, developmental, cultural, psychological, pathological, and/or environmental nature. The approved language is “related to.”

While in the past it may have seemed that the problem was the big issue, in this model it is the etiology that is key. If a patient is bleeding, the work lies in finding why he or she is bleeding. If a patient has inadequate caloric intake, the RD’s work is in correcting the cause, not simply identifying that the person is not eating. This step can also help you discover whether the RD can correct this nutritional issue. If the patient cannot consume food because his or her mouth is filled with a ventilator, that is not something you can solve directly. Determine whether this nutritional problem has a primary nutritional cause or whether it is a result of secondary factors that may be medical, genetic, or environmental. We’re good, but we can’t solve every problem a patient encounters.

This step in the process also unfolds complex issues. Perhaps the patient is gaining weight because of excessive intake. But is the excessive calorie intake caused by the patient’s medications or the head injury? Perhaps the person’s weight is not due to eating too much but by moving too little because last year he or she broke a hip and is now fearful of falling. Unraveling the true cause of the problem will help you determine how to prioritize interventions.

The last step in writing the nutrition diagnosis is to state the signs and symptoms. These defining characteristics are both subjective (symptoms) and objective (signs) and have been established for each nutrition diagnostic category. They answer the question of how you determined that the person had the problem you identified in step one. In the signs and symptoms step, you state what you found during your nutritional assessment to provide evidence that a nutrition-related problem exists and that the problem identified belongs in the selected diagnostic category.

The standardized language “as evidenced by” is how you link this part to the etiology. This correlates to the S and O of the old SOAP note format. Here is where you state things you learned during the patient interview and from lab values and other objective findings.

Here’s to the Future
This new method will help us focus our clinical work. Does anyone on the healthcare team really need to read the subjective part of a note stating the patient was pleasant or liked his or her lunch? Does charting that you will “monitor labs” or “follow patient” really show the vast knowledge you have and what you do to help this patient? However, if you link the subjective information—that the patient likes his or her lunch—to the real deal—that he or she loves all food and is binge eating—that is important. If you state which lab values you intend to monitor and why, such as checking the blood glucose values for your patient newly diagnosed with diabetes and will use that information to help the patient learn how to manage his or her disease, that is a chart note worth reading by everyone on the healthcare team.

As we all move to EMRs, standardized language will increase in importance. Imagine the researcher using a computer program to determine exactly how many RDs a hospital needs. If that researcher can easily scan hundreds of thousands of records and the nutrition issues are categorized, the interventions performed by the dietitians and dietetic technicians are defined, and the improved clinical outcomes of the patients are clear, then dietetic services rise in importance. If we do not adopt this model, then we are back in the dark ages charting in the back of the chart where nobody called “doctor” ever looked. “We should all support the nutrition diagnosis and nutrition care process,” says Kalman. “A proven standard of care and demonstrated outcomes will increase the income we can earn from third-party payers and increase respect for our profession.”

— Carol M. Meerschaert, RD, is a freelance writer, a corporate consultant, and a lecturer in Falmouth, Me. You can reach her at carol@nutritionresource.com.

1. Mathieu J, Foust M, Ouellette P, et al. Implementing nutrition diagnosis, step two in the Nutrition Care Process and model: Challenges and lessons learned in two health care facilities. J Am Diet Assoc. 2005:105(10):1636-1640.

2. Lacey K, Pritchett E. Nutrition Care Process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003:103(8):1061-1072.

3. Kohn L, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, D.C.: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 2000.

4. ADA Scientific Affairs and Research. Nutrition Diagnosis and Intervention: Standardized Language for the Nutrition Care Process. Chicago: American Dietetic Association; 2006.

Examples of Nutrition Diagnosis Statements2
• Excessive caloric intake (problem) “related to” (RT) frequent consumption of large portions of high-fat meals (etiology) “as evidenced by” average daily intake of calories exceeding recommended amount by 500 kilocalories and 12-pound weight gain during the past 18 months (signs).

• Inappropriate infant feeding practice RT lack of knowledge as evidenced by infant receiving bedtime juice in a bottle.

• Unintended weight loss RT inadequate provision of energy by enteral products as evidenced by 6-pound weight loss over past month.

• Risk of weight gain RT a recent decrease in daily physical activity following sports injury.

Steps in Nutrition Diagnosis2
• Derive the nutrition diagnosis from the assessment data.

• Identify and label the problem.

• Determine etiology (cause, contributing risk factors).

• Cluster signs and symptoms (defining characteristics).

• Rank the nutrition diagnoses.

• Validate the nutrition diagnosis with clients/community, family members, or other healthcare professionals when possible and appropriate.

• Document the nutrition diagnosis in a written PESS (problem, etiology, signs, and symptoms) statement.

• Reevaluate and revise nutrition diagnoses when additional assessment data become available.

For Your Bookshelf
Nutrition Diagnosis and Intervention: Standardized Language for the Nutrition Care Process
By American Dietetic Association (ADA) Scientific Affairs and Research
This guide includes essential tools and terminology to implement the Nutrition Care Process using the nutrition diagnosis standardized language to identify and label specific nutrition problems. New to this edition are sections on nutrition assessment and nutrition intervention terminology.
Softcover, 292 pages, 2006
ADA members: $15