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Nutrition Assessment and Monitoring and Evaluation Terminology This is a combined list of Nutrition Assessment and Monitoring and Evaluation terms. Shaded indicators are used ONLY for nutrition assessment. All of the other indicators are used for both assessment and monitoring and evaluation. Each term is designated with an alpha-numeric NCPT hierarchical code, followed by a five-digit (e.g., 99999) Academy SNOMED CT/LOINC unique identifier (ANDUID). Neither should be used in nutrition documentation. The ANDUID is for data tracking purposes in electronic health records. NCPT Code ANDUID NCPT Code ANDUID

  FOOD/NUTRITION-RELATED HISTORY (FH)

q Food additive intake (specify)

FH-1.4.2.6

10038

Food and nutrient intake, food and nutrient administration, medication and complementary/alternative medicine use, knowledge/beliefs/attitudes, behavior, food and supply availability, physical activity and function, nutrition-related patient/client-centered measures.

q Other (specify)

FH-1.4.2.7

10039

Caffeine intake (1.4.3) FH-1.4.3.1

10041

Food and Nutrient Intake (1)

Macronutrient Intake (1.5)

q Total caffeine intake

Fat and cholesterol, protein, carbohydrate, and fiber intake from all sources including food, beverages, supplements, and via enteral and parenteral routes.

Composition and adequacy of food and nutrient intake, meal and snack patterns, current and previous diets and/or food modifications, and eating environment.

Fat intake (1.5.1)

Energy Intake (1.1) Total energy intake from all sources including food, beverages, breastmilk/formula, supplements, and via enteral and parenteral routes.

Energy intake (1.1.1)

q Total energy intake

FH-1.1.1.1

10005

Food and Beverage Intake (1.2)

q Total fat intake

FH-1.5.1.1

10044

q Saturated fat intake

FH-1.5.1.2

10045

q Trans fatty acid intake

FH-1.5.1.3

10046

q Polyunsaturated fat intake

FH-1.5.1.4

10047

FH-1.5.1.4.1

11602

q Monounsaturated fat intake

FH-1.5.1.5

10048

q Omega-3 fatty acid intake

FH-1.5.1.6

10049

q Alphalinolenic acid intake

FH-1.5.1.6.1

11603

q Linoleic acid intake

Type, amount, and pattern of intake of foods and food groups, indices of diet quality, intake of fluids, breastmilk and infant formula

Fluid/beverage intake (1.2.1)

q Oral fluids

FH-1.2.1.1

10008

q Eicosapentaenoic acid intake

FH-1.5.1.6.2

11604

q Food-derived fluids

FH-1.2.1.2

10009

q Docosahexaenoic acid intake

FH-1.5.1.6.3

11605

q Liquid meal replacement or supplement

FH-1.2.1.3

10010

q Essential fatty acid intake

FH-1.5.1.7

10051

q Medium chain triglyceride intake

FH-1.5.1.8

11606

FH-1.5.2.1

10050

Food intake (1.2.2)

q Amount of food

FH-1.2.2.1

10012

q Types of food/meals

FH-1.2.2.2

10013

q Meal/snack pattern

FH-1.2.2.3

10014

q Diet quality index

FH-1.2.2.4

10015

q Total protein intake

FH-1.5.3.1

10053

q Food variety

FH-1.2.2.5

10016

q High biological value protein intake

FH-1.5.3.2

10054

q Casein intake

FH-1.5.3.3

10055

Cholesterol intake (1.5.2) q Dietary cholesterol intake

Protein intake (1.5.3)

Breastmilk/infant formula intake (1.2.3)

q Breastmilk intake

FH-1.2.3.1

10018

q Whey intake

FH-1.5.3.4

10056

q Infant formula intake

FH-1.2.3.2

10019

q Gluten intake

FH-1.5.3.5

11609

q Natural protein intake

FH-1.5.3.6

11610

q Total amino acid intake

FH-1.5.4.1

10057

q Essential amino acid intake

FH-1.5.4.2

10058

q Histidine intake

FH-1.5.4.2.1

11612

q Methionine intake

FH-1.5.4.2.2

11613

q Isoleucine intake

FH-1.5.4.2.3

11614

q Leucine intake

FH-1.5.4.2.4

11615

q Lysine intake

FH-1.5.4.2.5

11616

q Threonine intake

FH-1.5.4.2.6

11617

q Tryptophan intake

FH-1.5.4.2.7

11618

q Phenylalanine intake

FH-1.5.4.2.8

11619

q Valine intake

FH-1.5.4.2.9

11620

FH-1.5.4.3

11621

Enteral and Parenteral Nutrition Intake (1.3)

Amino acid intake (1.5.4)

Specialized nutrition support intake from all sources, e.g., enteral and parenteral routes.

Enteral nutrition intake (1.3.1)

q Enteral nutrition formula/solution

FH-1.3.1.1

10022

q Feeding tube flush

FH-1.3.1.2

10023

Parenteral nutrition intake (1.3.2)

q Parenteral nutrition formula/solution

FH-1.3.2.1

q IV fluids

FH-1.3.2.2

10025 10026

Bioactive Substance Intake (1.4) Alcohol, plant stanol and sterol esters, soy protein, psyllium and b-glucan, and caffeine intake from all sources, e.g., food, beverages, supplements, and via enteral and parenteral routes.

Alcohol intake (1.4.1)

q Nonessential amino acid intake

q Drink size/volume

FH-1.4.1.1

10029

q Frequency

FH-1.4.1.2

10030

q Arginine intake

FH-1.5.4.3.1

11622

q Pattern of alcohol consumption

FH-1.4.1.3

10031

q Glutamine intake

FH-1.5.4.3.2

11623

q Homocysteine intake

FH-1.5.4.3.3

11624

q Tyramine intake

FH-1.5.4.3.4

11625

q Tyrosine intake

FH-1.5.4.3.5

11626

q Total carbohydrate intake

FH-1.5.5.1

10060

q Complex carbohydrate intake

FH-1.5.5.2

11627

q Simple sugar carbohydrate intake

FH-1.5.5.3

11628

Bioactive substance intake (1.4.2)

q Plant stanol ester intake

FH-1.4.2.1

q Plant sterol ester intake

FH-1.4.2.2

q Soy protein intake

FH-1.4.2.3

10035

q Psyllium intake

FH-1.4.2.4

10827

q β-glucan intake

FH-1.4.2.5

10037

10034 10807

Carbohydrate intake (1.5.5)

1 Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.

Nutrition Assessment and Monitoring and Evaluation Terminology NCPT Code

ANDUID

NCPT Code

ANDUID

q Galactose intake

FH-1.5.5.4

11629

Food and Nutrient Administration (2)

q Lactose intake

FH-1.5.5.5

11630

q Fructose intake

FH-1.5.5.6

11631

Current and previous diets and/or food modifications, eating environment, and enteral and parenteral nutrition administration.

q Glycemic index

FH-1.5.5.7

10063

Diet History (2.1)

q Glycemic load

FH-1.5.5.8

10064

q Source of carbohydrate

FH-1.5.5.9

10065

Description of food and drink regularly provided or consumed, past diets followed or prescribed and counseling received, and the eating environment.

q Insulin-to-carbohydrate ratio

FH-1.5.5.10

10066

 

Diet order (2.1.1)

Fiber intake (1.5.6)

q Total fiber intake

FH-1.5.6.1

10068

q Soluble fiber intake

FH-1.5.6.2

10069

q Insoluble fiber intake

FH-1.5.6.3

10070

q General, healthful diet order

FH-2.1.1.1

10113

q Modified diet order

FH-2.1.1.2

10114

q Enteral nutrition order

FH-2.1.1.3

10115

q Parenteral nutrition order

FH-2.1.1.4

10116

q Previously prescribed diets

FH-2.1.2.1

10118

q Previous diet/nutrition education/counseling

FH-2.1.2.2

10119

Diet experience (2.1.2)

Micronutrient Intake (1.6) Vitamin and mineral intake from all sources including food, beverages, supplements, and via enteral and parenteral routes.

q Self-selected diet/s followed

FH-2.1.2.3

10120

q A (1)

10073

q Dieting attempts

FH-2.1.2.4

10121

q C (2)

10074

q Food allergies

FH-2.1.2.5

10805

10075

q Food intolerance

FH-2.1.2.6

10806

q Location

FH-2.1.3.1

10123

q Atmosphere

FH-2.1.3.2

10124

q Caregiver/companion

FH-2.1.3.3

10125

q Appropriate breastfeeding

FH-2.1.3.4

10126

FH-2.1.3.5

10127

Vitamin intake (1.6.1)

q D (3)

Eating environment (2.1.3)

q E (4)

10076

q K (5)

10077

q Thiamin (6)

10078

q Riboflavin (7)

10079

q Niacin (8)

10080

q Folate (9)

10081

q B6 (10)

10082

q B12 (11)

10083

q Enteral access

FH-2.1.4.1

10129

q Pantothenic acid (12)

10084

q Parenteral access

FH-2.1.4.2

10130

q Biotin (13)

10085

q Body position, EN

FH-2.1.4.3

10804

q Multivitamin (14)

10086

accommodations/facility

q Eats alone

Enteral and parenteral nutrition administration (2.1.4)

Fasting (2.1.5) q Fasting pattern in one calendar day, reported

FH-2.1.5.1

11633

q Calcium (1)

10089

q Fasting pattern in one calendar week, reported

FH-2.1.5.2

11634

q Chloride (2)

10090

q Fasting pattern in one calendar month, reported

FH-2.1.5.3

11635

q Fasting pattern in one calendar year, reported

FH-2.1.5.4

11636

q Fasting tolerance, reported

FH-2.1.5.5

11637

Mineral/element intake (1.6.2)

q Iron (3)

10091

q Magnesium (4)

10092

q Potassium (5)

10093

q Phosphorus (6)

10094

Prescription and over-the-counter medications, including herbal preparations and complementary/alternative medicine products used.

q Sodium (7)

10095

Medications (3.1)

q Zinc (8)

10096

q Prescription medication use

FH-3.1.1

10820

q Sulfate (9)

10097

q OTC medication use

FH-3.1.2

10134

q Fluoride (10)

10098

q Misuse of medication

FH-3.1.3

10135

FH-3.2.1

10137

Medication and Complementary/Alternative Medicine Use (3)

Complementary/Alternative Medicine (3.2)

q Copper (11)

10099

q Iodine (12)

10100

q Selenium (13)

10101

q Manganese (14)

10102

q Chromium (15)

10103

q Molybdenum (16)

10104

Understanding of nutrition-related concepts and conviction of the truth and feelings/emotions toward some nutrition-related statement or phenomenon, along with readiness to change nutrition-related behaviors.

q Boron (17)

10105

Food and nutrition knowledge/skill (4.1)

q Cobalt (18)

10106

q Area(s) and level of knowledge/skill

FH-4.1.1

10848

q Multi-mineral (19)

10107

q Diagnosis specific or global nutrition-related

FH-4.1.2

10143

q Multi-trace element (20)

10108

q Nutrition-related complementary/alternative medicine use

Knowledge/Beliefs/Attitudes (4)

knowledge score

Beliefs and attitudes (4.2)

2 Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.

Nutrition Assessment and Monitoring and Evaluation Terminology NCPT Code

ANDUID

NCPT Code

ANDUID

q Conflict with personal/family value system

FH-4.2.1

10145

q Availability of shopping facilities

FH-6.2.1

10192

q Distorted body image

FH-4.2.2

10146

q Procurement of safe food

FH-6.2.2

10800

q End-of-life decisions

FH-4.2.3

10147

q Appropriate meal preparation facilities

FH-6.2.3

10194

q Motivation

FH-4.2.4

10148

q Availability of safe food storage

FH-6.2.4

10195

q Preoccupation with food/nutrients

FH-4.2.5

10149

q Appropriate storage technique

FH-6.2.5

10196

q Preoccupation with weight

FH-4.2.6

10150

q Identification of safe food

FH-6.2.6

10801

q Readiness to change nutrition-related behaviors

FH-4.2.7

10151

q Self-efficacy

FH-4.2.8

10152

q Availability of potable water

FH-6.3.1

10198

q Self-talk/cognitions

FH-4.2.9

10153

q Appropriate water decontamination

FH-6.3.2

10199

q Unrealistic nutrition-related goals

FH-4.2.10

10154

q Unscientific beliefs/attitudes

FH-4.2.11

10155

q Access to food and nutrition-related supplies

FH-6.4.1

10201

q Food preferences

FH-4.2.12

10156

q Access to assistive eating devices

FH-6.4.2

10202

q Emotions

FH-4.2.13

10157

q Access to assistive food preparation devices

FH-6.4.3

10203

 

Safe water availability (6.3)

Food and nutrition-related supplies availability (6.4)

Behavior (5)

Physical Activity and Function (7)

Patient/client activities and actions, which influence achievement of nutrition-related goals.

Physical activity, cognitive and physical ability to engage in specific tasks, e.g., breastfeeding and self-feeding.

Adherence (5.1)

Breastfeeding (7.1)

q Self-reported adherence score q Nutrition visit attendance

FH-5.1.1 FH-5.1.2

10160

q Initiation of breastfeeding

FH-7.1.1

10206

10161

q Duration of breastfeeding

FH-7.1.2

10207

q Exclusive breastfeeding

FH-7.1.3

10208

q Breastfeeding problems

FH-7.1.4

10209

FH-7.2.1

10211

q Physical ability to self-feed

FH-7.2.2

10212

q Ability to position self in relation to plate

FH-7.2.3

10213

q Receives assistance with intake

FH-7.2.4

10214

q Ability to use adaptive eating devices

FH-7.2.5

10215

q Cognitive ability to complete tasks for meal

FH-7.2.6

10216

q Remembers to eat

FH-7.2.7

10139

q Recalls eating

FH-7.2.8

10218

q Mini Mental State Examination Score

FH-7.2.9

10219

q Nutrition-related activities of daily living (ADL)

FH-7.2.10

10220

FH-7.2.11

10221

q Ability to recall nutrition goals

FH-5.1.3

10162

q Self-monitoring at agreed upon rate

FH-5.1.4

10163

q Self-management as agreed upon

FH-5.1.5

10164

q Avoidance

FH-5.2.1

10166

q Restrictive eating

FH-5.2.2

10167

q Cause of avoidance behavior

FH-5.2.3

10168

Nutrition-related ADLs and IADLs (7.2)

q Physical ability to complete tasks for meal

Avoidance behavior (5.2)

preparation

Bingeing and purging behavior (5.3)

q Binge eating behavior

FH-5.3.1

10170

q Purging behavior

FH-5.3.2

10171

q Meal duration

FH-5.4.1

10173

q Percent of meal time spent eating

FH-5.4.2

10174

q Preference to drink rather than eat

FH-5.4.3

10175

q Refusal to eat/chew

FH-5.4.4

10176

q Spitting food out

FH-5.4.5

10177

q Rumination

FH-5.4.6

10178

q Patient/client/caregiver fatigue during feeding

FH-5.4.7

10179

q Physical activity history

FH-7.3.1

10223

q Willingness to try new foods

FH-5.4.8

10180

q Consistency

FH-7.3.2

10224

q Limited number of accepted foods

FH-5.4.9

10181

q Frequency

FH-7.3.3

10225

q Rigid sensory preferences

FH-5.4.10

10182

q Duration

FH-7.3.4

10226

q Intensity

FH-7.3.5

10227

q Type of physical activity

FH-7.3.6

10228

q Strength

FH-7.3.7

10229

q TV/screen time

FH-7.3.8

10230

Factors that affect intake and availability of a sufficient quantity of safe, healthful food as well as food/nutrition-related supplies.

q Other sedentary activity time

FH-7.3.9

10231

q Involuntary physical movement

FH-7.3.10

10232

Food/nutrition program participation (6.1)

q Non exercise activity thermogenesis

FH-7.3.11

10233

preparation

Mealtime behavior (5.4)

score

q Nutrition-related instrumental activities of daily living (IADL) score

Physical activity (7.3)

process resulting in inadequate intake

Social network (5.5)

q Ability to build and utilize social network

FH-5.5.1

10184

Factors Affecting Access to Food and Food/Nutrition-Related Supplies (6)

Factors affecting access to physical activity (7.4)

q Eligibility for government programs

FH-6.1.1

10187

q Participation in government programs

FH-6.1.2

10188

q Neighborhood safety

FH-7.4.1

10822

q Eligibility for community programs

FH-6.1.3

10189

q Walkability of neighborhood

FH-7.4.2

10823

q Participation in community programs

FH-6.1.4

10190

q Proximity to parks/green space

FH-7.4.3

10824

q Access to physical activity facilities/programs

FH-7.4.4

10825

Safe food/meal availability (6.2)

3 Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.

Nutrition Assessment and Monitoring and Evaluation Terminology NCPT Code

ANDUID

NCPT Code

ANDUID

  Nutrition-Related Patient/Client-Centered Measures (8)

q Prothrombin time, PT

BD-1.4.9

10279

Patient/client’s perception of his or her nutrition intervention and its impact on life.

q Partial thromboplastin time, PTT

BD-1.4.10

10280

Nutrition quality of life (8.1)

q INR (ratio)

BD-1.4.11

10281

q Amylase

BD-1.4.12

10283

q Lipase

BD-1.4.13

10284

q Fecal fat, 24 hour

BD-1.4.14

11242

q Fecal fat, 72 hour

BD-1.4.15

11243

q Fecal fat, qualitative

BD-1.4.16

11244

q Fecal calprotectin

BD-1.4.17

11245

10239

q Fecal lactoferrin

BD-1.4.18

11246

10240

q Pancreatic elastase

BD-1.4.19

11150

10241

q 5'nucleotidase

BD-1.4.20

11247

10242

q D-xylose

BD-1.4.21

10286

10243

q Lactulose hydrogen breath test

BD-1.4.22

11248

10244

q Lactose hydrogen breath test

BD-1.4.23

11249

10245

q Fructose hydrogen breath test

BD-1.4.24

11250

q Glucose hydrogen breath test

BD-1.4.25

11251

q Urea hydrogen breath test

BD-1.4.26

11252

q Intestinal biopsy

BD-1.4.27

10288

q Stool culture

BD-1.4.28

10289

q Gastric emptying time

BD-1.4.29

10290

q Small bowel transit time

BD-1.4.30

10291

q Abdominal X-ray

BD-1.4.31

11253

q Abdominal CT

BD-1.4.32

11254

q Abdominal ultrasound

BD-1.4.33

11255

q Endoscopic ultrasound

BD-1.4.34

11256

q Pelvic CT

BD-1.4.35

11257

q Nutrition quality of life responses

FH-8.1.1

10236

ANTHROPOMETRIC MEASUREMENTS (AD) Height, weight, body mass index (BMI), growth pattern indices/percentile ranks, and weight history.

Body composition/growth/weight history (1.1) q Height/length

AD-1.1.1

q Weight

AD-1.1.2

q Frame size

AD-1.1.3

q Weight change

AD-1.1.4

q Body mass index

AD-1.1.5

q Growth pattern indices/percentile ranks q Body compartment estimates

AD-1.1.6 AD-1.1.7

BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES (BD) Laboratory data, (e.g., electrolytes, glucose, and lipid panel) and tests (e.g., gastric emptying time, resting metabolic rate).

Acid-base balance (1.1) q Arterial pH

BD-1.1.1

10248

q Arterial bicarbonate

BD-1.1.2

10249

q Partial pressure of carbon dioxide in arterial blood, PaCO2

BD-1.1.3

10250

q Partial pressure of oxygen in arterial blood, PaO2

BD-1.1.4

q Venous pH

BD-1.1.5

10252

q Modified barium swallow

BD-1.4.36

11258

q Venous bicarbonate

BD-1.1.6

10253

q Barium swallow

BD-1.4.37

11259

q Esophagogastroduodenoscopy

BD-1.4.38

11260

10251

Electrolyte and renal profile (1.2) q BUN

BD-1.2.1

10255

q ERCP

BD-1.4.39

11261

q Creatinine

BD-1.2.2

10256

q Capsule endoscopy

BD-1.4.40

11262

q BUN:creatinine ratio

BD-1.2.3

10257

q Esophageal manometry

BD-1.4.41

11263

q Glomerular filtration rate

BD-1.2.4

10258

q Esophageal pH test

BD-1.4.42

11264

q Sodium

BD-1.2.5

10259

q Gastroesophageal reflux monitoring

BD-1.4.43

11265

q Chloride

BD-1.2.6

10260

q Gastrointestinal sphincter monitoring

BD-1.4.44

11266

q Potassium

BD-1.2.7

10261

q Urate

BD-1.4.45

11638

q Magnesium

BD-1.2.8

10262

q Calcium, serum

BD-1.2.9

10263

q Glucose, fasting

BD-1.5.1

10295

q Calcium, ionized

BD-1.2.10

10264

q Glucose, casual

BD-1.5.2

10296

q Phosphorus

BD-1.2.11

10265

q HgbA1c

BD-1.5.3

10297

q Serum osmolality

BD-1.2.12

10266

q Preprandial capillary plasma glucose

BD-1.5.4

10298

q Parathyroid hormone

BD-1.2.13

10267

q Peak postprandial capillary plasma glucose

BD-1.5.5

10299

q Glucose tolerance test

BD-1.5.6

10300

q Cortisol level

BD-1.5.7

10301

q IGF-binding protein

BD-1.5.8

10302

Glucose/endocrine profile (1.5)

Essential fatty acid profile (1.3) BD-1.3.1

q Triene:Tetraene ratio

10269

Gastrointestinal profile (1.4) q Alkaline phosphatase

BD-1.4.1

10271

q Thyroid stimulating hormone

BD-1.5.9

11639

q Alanine aminotransferase, ALT

BD-1.4.2

10272

q Thyroxine test

BD-1.5.10

11640

q Aspartate aminotransferase, AST

BD-1.4.3

10273

q Triiodothyronine

BD-1.5.11

11641

q Gamma glutamyl transferase, GGT

BD-1.4.4

10274

q Adrenocorticotropic hormone

BD-1.5.12

11642

q Gastric residual volume

BD-1.4.5

10275

q Follicle stimulating hormone

BD-1.5.13

11643

q Bilirubin, total

BD-1.4.6

10276

q Growth hormone

BD-1.5.14

11644

q Ammonia, serum

BD-1.4.7

10277

q Luteinizing hormone

BD-1.5.15

11645

q Toxicology report, including alcohol

BD-1.4.8

10278

Inflammatory profile (1.6)

4 Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.

Nutrition Assessment and Monitoring and Evaluation Terminology NCPT Code

ANDUID

BD-1.6.1

10305

NCPT Code

ANDUID

  q C-reactive protein

Lipid profile (1.7)

q Alanine

BD-1.11.18

11162

q Citrulline

BD-1.11.19

11163

q Cholesterol, serum

BD-1.7.1

10307

q Valine

BD-1.11.20

11164

q Cholesterol, HDL

BD-1.7.2

10308

q Cysteine

BD-1.11.21

11165

q Cholesterol, LDL

BD-1.7.3

10309

q Methionine

BD-1.11.22

11166

q Cholesterol, non-HDL

BD-1.7.4

10310

q Isoleucine

BD-1.11.23

11167

q Total cholesterol:HDL cholesterol

BD-1.7.5

10311

q Leucine

BD-1.11.24

11168

q LDL:HDL

BD-1.7.6

10312

q Ornithine

BD-1.11.25

11169

10313

q Lysine

BD-1.11.26

11170

q Histidine

BD-1.11.27

11171

10315

q Arginine

BD-1.11.28

11172

10316

q Lysine:arginine

BD-1.11.29

11173

q Tryptophan

BD-1.11.30

11174

10318

q Plasma organic acid panel

BD-1.11.31

11175

BD-1.11.32

11176

q Triglycerides, serum

BD-1.7.7

Metabolic rate profile (1.8) q Resting metabolic rate, measured q Respiratory quotient, measured

BD-1.8.1 BD-1.8.2

Mineral profile (1.9) q Copper, serum or plasma

BD-1.9.1

q Iodine, urinary excretion

BD-1.9.2

10319

q Organic acids/creatinine

q Zinc, serum or plasma

BD-1.9.3

10320

q 3-hydroxybutyrate

BD-1.11.33

11181

q Boron, serum or plasma

BD-1.9.4

10841

q 3-hydroxyisovalerate

BD-1.11.34

11182

q Chromium, serum or urinary

BD-1.9.5

10842

q Acetoacetate

BD-1.11.35

11183

q Fluoride, plasma

BD-1.9.6

10843

q Ethylmalonate

BD-1.11.36

11184

q Manganese, urinary, blood, plasma

BD-1.9.7

10844

q Succinate

BD-1.11.37

11185

q Molybdenum, serum

BD-1.9.8

10845

q Fumarate

BD-1.11.38

11186

q Selenium, serum or urinary

BD-1.9.9

10846

q Glutarate

BD-1.11.39

11187

q 3-methylglutarate

BD-1.11.40

11188

10323

q Adipate

BD-1.11.41

11189

10324

q 2-hydroxyglutarate

BD-1.11.42

11190

10325

q 3-hydroxyphenylacetate

BD-1.11.43

11191

10326

q 2-ketoglutarate

BD-1.11.44

11192

10327

q Citrate

BD-1.11.45

11193

10328

q Propionate

BD-1.11.46

11194

10329

q Methylcitrate

BD-1.11.47

11195

10330

q 3-hydroxy propionate

BD-1.11.48

11196

10331

q β-hydroxy butyrate

BD-1.11.49

11197

10332

q Creatine kinase

BD-1.11.50

11198

BD-1.11.51

11199

Nutritional anemia profile (1.10) q Hemoglobin

BD-1.10.1

q Hematocrit

BD-1.10.2

q Mean corpuscular volume q Red blood cell folate

BD-1.10.3 BD-1.10.4

q Red cell distribution width q B12, serum

BD-1.10.5 BD-1.10.6

q Methylmalonic acid, serum q Folate, serum

BD-1.10.7 BD-1.10.8

q Homocysteine, serum

BD-1.10.9

q Ferritin, serum

BD-1.10.10

q Iron, serum

BD-1.10.11

10333

q Troponin I. cardiac

q Total iron-binding capacity

BD-1.10.12

10334

q Troponin T. cardiac

BD-1.11.52

11200

q Transferrin saturation

BD-1.10.13

10335

q B-type natriuretic peptide

BD-1.11.53

11201

q Succinylacetone

BD-1.11.54

11202

Protein profile (1.11) q Albumin

BD-1.11.1

10337

q Total serum immunoglobulin A

BD-1.11.55

11267

q Prealbumin

BD-1.11.2

10338

q Tissue transglutaminase antibodies (IgA)

BD-1.11.56

11268

q Transferrin

BD-1.11.3

10339

q Tissue transglutaminase antibodies (IgG)

BD-1.11.57

11269

10340

q Deamidated gliadin peptide antibodies (IgG)

BD-1.11.58

11270

10341

q Endomysial antibodies

BD-1.11.59

11271

10342

q Carbohydrate-deficient transferrin

BD-1.11.60

10847

q Phenylalanine, plasma

BD-1.11.4

q Tyrosine, plasma

BD-1.11.5

q Amino acid panel

BD-1.11.6

q Phenylalanine, dried blood spot

BD-1.11.7

11151

Urine profile (1.12)

q Tyrosine, dried blood spot

BD-1.11.8

11152

q Urine color

BD-1.12.1

10345

11153

q Urine osmolality

BD-1.12.2

10346

11154

q Urine specific gravity

BD-1.12.3

10347

11155

q Urine volume

BD-1.12.4

10349

11156

q Urine calcium, 24 hour

BD-1.12.5

11272

11157

q Urine d-xylose

BD-1.12.6

11273

11158

q Urine glucose

BD-1.12.7

11203

11159

q Urine ketones

BD-1.12.8

11204

BD-1.12.9

11205

BD-1.12.10

11206

q Phenylalanine:tyrosine q Hydroxyproline q Threonine q Serine q Asparagine q Glutamate q Glutamine

BD-1.11.9 BD-1.11.10 BD-1.11.11 BD-1.11.12 BD-1.11.13 BD-1.11.14 BD-1.11.15

q Proline

BD-1.11.16

11160

q Urine sodium

q Glycine

BD-1.11.17

11161

q Urine microalbumin

5 Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.

Nutrition Assessment and Monitoring and Evaluation Terminology NCPT Code

ANDUID

NCPT Code

ANDUID

q Urine protein, random

BD-1.12.11

11207

11238

BD-1.12.12

11208

q MCAD enzyme assay in fibroblasts or other tissues

BD-1.15.9

q Urine protein, 24 hour q Urine uric acid, random

BD-1.12.13

11209

q Fatty acid β-oxidation in fibroblasts

BD-1.15.10

11239

q Urine uric acid, 24 hour

BD-1.12.14

11210

q Urine organic acid panel

BD-1.12.15

11211

NUTRITION-FOCUS PHYSICAL FINDINGS (PD)

q Urine glutarate

BD-1.12.16

11212

q Urine methylmalonate

BD-1.12.17

11213

q Urine acylglycines/creatinine

BD-1.12.18

11214

Findings from a nutrition-focused physical exam, interview, or the medical record including muscle and subcutaneous fat, oral health, suck/swallow/breathe ability, appetite, and affect.

q Urine argininosuccinate

BD-1.12.19

11215

q Urine succinylacetone/creatinine

BD-1.12.20

11216

q Urine orotate

BD-1.12.21

11217

q Urine orotate/creatinine

BD-1.12.22

11218

q Urine 2-hydroxyisovalerate

BD-1.12.23

11219

q Urine 2-oxoisovalerate

BD-1.12.24

11220

q Urine galactitol

BD-1.12.25

11221

q Urine reducing substances

BD-1.12.26

11222

q Urine porphyrins

BD-1.12.27

11274

 

Nutrition-focused physical findings (1.1) q Overall findings (1)

Vitamin profile (1.13) q Vitamin A, serum or plasma retinol

BD-1.13.1

10351

q Vitamin C, plasma or serum

BD-1.13.2

10352

q Vitamin D, 25-hydroxy

BD-1.13.3

10353

q Vitamin E, plasma alpha-tocopherol

BD-1.13.4

10354

q Thiamin, activity coefficient for erythrocyte transketolase activity

BD-1.13.5

10355

q Asthenia

PD-1.1.1.1

11646

q Buffalo hump

PD-1.1.1.2

11647

q Cachexia

PD-1.1.1.3

11648

q Cushingoid appearance

PD-1.1.1.4

11649

q Ectomorph

PD-1.1.1.5

11650

q Endomorph

PD-1.1.1.6

11651

q Lethargic

PD-1.1.1.7

11652

q Mesomorph

PD-1.1.1.8

11653

q Neglect of personal hygiene

PD-1.1.1.9

11654

q Obese

PD-1.1.1.10

11655

q Short stature for age

PD-1.1.1.11

11656

q Tall stature

PD-1.1.1.12

11657

q Atrophy of orbital fat

PD-1.1.2.1

11659

q Excess subcutaneous fat

PD-1.1.2.2

11660

q Loss of subcutaneous fat

PD-1.1.2.3

11661

q Central adiposity

PD-1.1.2.4

11662

q Bow legs

PD-1.1.3.1

11664

q Frontal bossing

PD-1.1.3.2

11665

q Harrison’s sulcus

PD-1.1.3.3

11666

q Rachitic rosary

PD-1.1.3.4

11667

q Rickets

PD-1.1.3.5

11668

q Scoliosis

PD-1.1.3.6

11669

q Adipose (2)

q Riboflavin, activity coefficient for erythrocyte glutathione reductase activity

BD-1.13.6

q Niacin, urinary N’methyl-nicotinamide concentration

BD-1.13.7

q Vitamin B6, plasma or serum pyridoxal 5’phosphate concentration

BD-1.13.8

q Pantothenic acid, urinary pantothenate excretion, plasma

BD-1.13.9

q Biotin, urinary 3-hydroxyisovaleric acid excretion

BD-1.13.10

11275

q Biotin, lymphocyte propionyl-CoA carboxylase in pregnancy, serum

BD-1.13.11

11276

q Biotinidase

BD-1.13.12

11223

q Absent breath sounds

PD-1.1.4.1

11670

q Protein induced by vitamin K absence or antagonist II

BD-1.13.13

11224

q Bradycardia

PD-1.1.4.2

11671

q Bradypnea

PD-1.1.4.3

11672

q Decreased breath sounds

PD-1.1.4.4

11673

10356 10357

q Bones (3) 10358 10850

q Cardiovascular-pulmonary system (4)

Carbohydrate metabolism profile (1.14) q Galactose-1-phosphate in red blood cell

BD-1.14.1

11226

q Dyspnea

PD-1.1.4.5

11674

q Galactose-1-phosphate uridyl transferase

BD-1.14.2

11227

q Increased breath sounds

PD-1.1.4.6

11675

q Fructose

BD-1.14.3

11228

q Normal breath sounds

PD-1.1.4.7

11676

q Lactate

BD-1.14.4

11177

q Tachypnea

PD-1.1.4.8

11677

q Pyruvate

BD-1.14.5

11178

q Tachycardia

PD-1.1.4.9

11678

q Lactate:pyruvate

BD-1.14.6

11179

q Respiratory crackles

PD-1.1.4.10

11679

Fatty acid profile (1.15)

q Digestive system (5)

q Acylcarnitine panel

BD-1.15.1

11230

q Abdominal bloating

PD-1.1.5.1

11684

q Acylcarnitine, plasma

BD-1.15.2

11231

q Abdominal cramping

PD-1.1.5.2

11685

q Free carnitine

BD-1.15.3

11232

q Abdominal distension

PD-1.1.5.3

11686

q Total carnitine

BD-1.15.4

11233

q Abdominal pain

PD-1.1.5.4

11687

q Free carnitine:total carnitine

BD-1.15.5

11234

q Absence of bowel sounds

PD-1.1.5.5

11688

q Fatty acid panel mitochondrial C8-C18

BD-1.15.6

11235

q Anorexia

PD-1.1.5.6

11689

q Fatty acid panel essential C12-C22

BD-1.15.7

11236

q Ascites

PD-1.1.5.7

11690

q Fatty acid panel peroxisomal C22-C26

BD-1.15.8

11237

q Bulky stool

PD-1.1.5.8

11691

q Constipation

PD-1.1.5.9

11692

6 Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.

Nutrition Assessment and Monitoring and Evaluation Terminology NCPT Code

ANDUID

NCPT Code

ANDUID

q Decrease in appetite

PD-1.1.5.10

11693

q Joint arthralgia

PD-1.1.7.21

11748

q Diarrhea

PD-1.1.5.11

11694

q Lower limb spasticity

PD-1.1.7.22

11749

q Early satiety

PD-1.1.5.12

11695

q Peripheral cyanosis

PD-1.1.7.23

11750

q Epigastric pain

PD-1.1.5.13

11696

q Spasticity

PD-1.1.7.24

11751

q Excessive appetite

PD-1.1.5.14

11697

q Tetany

PD-1.1.7.25

11752

q Excessive belching

PD-1.1.5.15

11698

q Upper limb spasticity

PD-1.1.7.26

11753

q Excessive flatus

PD-1.1.5.16

11699

q Fatty stool

PD-1.1.5.17

11700

q Abnormal vision

PD-1.1.8.1

11755

q Heartburn

PD-1.1.5.18

11701

q Angular blepharitis

PD-1.1.8.2

11756

q Hyperactive bowel sounds

PD-1.1.5.19

11702

q Biotot’s spots

PD-1.1.8.3

11757

q Hypoactive bowel sounds

PD-1.1.5.20

11703

q Circles under eyes

PD-1.1.8.4

11758

q Increased appetite

PD-1.1.5.21

11704

q Corneal arcus

PD-1.1.8.5

11759

q Liquid stool

PD-1.1.5.22

11705

q Conjunctival discoloration

PD-1.1.8.6

11760

q Loose stool

PD-1.1.5.23

11706

q Conjunctival hemorrhage

PD-1.1.8.7

11761

q Nausea

PD-1.1.5.24

11707

q Conjunctival keratinization

PD-1.1.8.8

11762

q Normal bowel sounds

PD-1.1.5.25

11708

q Excessive tear production

PD-1.1.8.9

11763

q Retching

PD-1.1.5.26

11709

q Keratomalacia

PD-1.1.8.10

11764

q Vomiting

PD-1.1.5.27

11710

q Jaundiced sclera

PD-1.1.8.11

11765

q Night blindness

PD-1.1.8.12

11766

 

q Eyes (8)

q Edema (6) q +1 pitting edema

PD-1.1.6.1

11712

q Ophthalmoplegia

PD-1.1.8.13

11767

q +2 pitting edema

PD-1.1.6.2

11713

q Sunken eyes

PD-1.1.8.14

11768

q +3 pitting edema

PD-1.1.6.3

11714

q Xerophthalmia

PD-1.1.8.15

11769

q +4 pitting edema

PD-1.1.6.4

11715

q Xanthelasma

PD-1.1.8.16

11770

q Anasarca

PD-1.1.6.5

11716

q Ankle edema

PD-1.1.6.6

11717

q Amenorrhea

PD-1.1.9.1

11772

q Edema of calf

PD-1.1.6.7

11718

q Anuria

PD-1.1.9.2

11773

q Edema of eyelid

PD-1.1.6.8

11719

q Delay in sexual development and/or puberty

PD-1.1.9.3

11774

q Edema of foot

PD-1.1.6.9

11720

q Menorrhagia

PD-1.1.9.4

11775

q Edema of hand

PD-1.1.6.10

11721

q Oliguria

PD-1.1.9.5

11776

q Edema of scrotum

PD-1.1.6.11

11722

q Polyuria

PD-1.1.9.6

11777

q Edema of thigh

PD-1.1.6.12

11723

q Edema of vulva

PD-1.1.6.13

11724

q Abnormal keratinization of hair follicle

PD-1.1.10.1

11779

q Mucosal edema

PD-1.1.6.14

11725

q Alopecia

PD-1.1.10.2

11780

q Sacral edema

PD-1.1.6.15

11726

q Brittle hair

PD-1.1.10.3

11781

q Corkscrew hairs

PD-1.1.10.4

11782

q Genitourinary system (9)

q Hair (10)

q Extremities (7) q Amputated foot

PD-1.1.7.1

11728

q Dry hair

PD-1.1.10.5

11783

q Amputated hand

PD-1.1.7.2

11729

q Fine hair

PD-1.1.10.6

11784

q Amputated leg

PD-1.1.7.3

11730

q Follicular hyperkeratosis

PD-1.1.10.7

11785

q Athetoid movement

PD-1.1.7.4

11731

q Hair changes due to malnutrition

PD-1.1.10.8

11786

q Decreased range of ankle movement

PD-1.1.7.5

11732

q Hair lacks luster

PD-1.1.10.9

11787

q Decreased range of cervical spine movement

PD-1.1.7.6

11733

q Hypertrichosis

PD-1.1.10.10

11788

q Decreased range of elbow movement

PD-1.1.7.7

11734

q Increased loss of hair

PD-1.1.10.11

11789

q Decreased range of finger movement

PD-1.1.7.8

11735

q Nutritional hair color change

PD-1.1.10.12

11790

q Decreased range of foot movement

PD-1.1.7.9

11736

q White hair

PD-1.1.10.13

11791

q Decreased range of hip movement

PD-1.1.7.10

11737

q Decreased range of knee movement

PD-1.1.7.11

11738

q Altered olfactory sense

PD-1.1.11.1

11793

q Decreased range of lumbar spine movement

PD-1.1.7.12

11739

q Anosmia

PD-1.1.11.2

11794

q Decreased range of shoulder movement

PD-1.1.7.13

11740

q Bulging fontanelle

PD-1.1.11.3

11795

q Decreased range of subtalar movement

PD-1.1.7.14

11741

q Epistaxis

PD-1.1.11.4

11796

q Decreased range of thumb movement

PD-1.1.7.15

11742

q Headache

PD-1.1.11.5

11797

q Decreased range of toe movement

PD-1.1.7.16

11743

q Hyposmia

PD-1.1.11.6

11798

q Decreased range of thoracic spine movement

PD-1.1.7.17

11744

q Macrocephaly

PD-1.1.11.7

11799

q Decreased range of wrist movement

PD-1.1.7.18

11745

q Microcephaly

PD-1.1.11.8

11800

q Hypertonia

PD-1.1.7.19

11746

q Nasal mucosa dry

PD-1.1.11.9

11801

q Hypotonia

PD-1.1.7.20

11747

q Sunken fontanelle

PD-1.1.11.10

11802

q Head (11)

7 Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.

Nutrition Assessment and Monitoring and Evaluation Terminology NCPT Code

ANDUID

q Beau’s lines

PD-1.1.12.1

11804

q Clubbing of nails

PD-1.1.12.2

11805

q Flaking of nails

PD-1.1.12.3

11806

q Koilonychia

PD-1.1.12.4

11807

q Leukonychia

PD-1.1.12.5

q Longitudinal grooving of nails

NCPT Code

ANDUID

  q Hand and nails (12)

q Neck (15) q Goiter

PD-1.1.15.1

11859

q Abnormal gait

PD-1.1.16.1

11860

q Absent reflex

PD-1.1.16.2

11861

11808

q Asterixis

PD-1.1.16.3

11862

PD-1.1.12.6

11809

q Ataxia

PD-1.1.16.4

11863

q Muehrcke’s lines

PD-1.1.12.7

11810

q Clouded consciousness

PD-1.1.16.5

11864

q Nail changes

PD-1.1.12.8

11811

q Cranial nerve finding

PD-1.1.16.6

11865

q Palmer erythema

PD-1.1.12.9

11812

q Decreased vibratory sense

PD-1.1.16.7

11866

q Ridged nails

PD-1.1.12.10

11813

q Delirious

PD-1.1.16.8

11867

q Splits in nails

PD-1.1.12.11

11814

q Dementia

PD-1.1.16.9

11868

q Thin nails

PD-1.1.12.12

11815

q Depressed mood

PD-1.1.16.10

11869

q Trachyonychia

PD-1.1.12.13

11816

q Disoriented

PD-1.1.16.11

11870

q Splinter hemorrhage under nails

PD-1.1.12.14

11817

q Dizziness

PD-1.1.16.12

11871

q White flecks in nails

PD-1.1.12.15

11818

q Feels cold

PD-1.1.16.13

11872

q Flat affect

PD-1.1.16.14

11873

q Nerves, cognition, and feelings (16)

q Mouth (13) q Ageusia

PD-1.1.13.1

11820

q Hyperreflexia

PD-1.1.16.15

11874

q Angular stomatitis

PD-1.1.13.2

11821

q Hyporeflexia

PD-1.1.16.16

11875

q Aphthous ulcer of mouth

PD-1.1.13.3

11822

q Inappropriate affect

PD-1.1.16.17

11876

q Aptyalism

PD-1.1.13.4

11823

q Many seizures a day

PD-1.1.16.18

11877

q Blue lips

PD-1.1.13.5

11824

q Numbness of foot

PD-1.1.16.19

11878

q Blue line on gingiva

PD-1.1.13.6

11825

q Numbness of hand

PD-1.1.16.20

11879

q Candidiasis of the mouth

PD-1.1.13.7

11826

q Peripheral nerve disease

PD-1.1.16.21

11880

q Cheilosis

PD-1.1.13.8

11827

q Tremor of outstretched hand

PD-1.1.16.22

11881

q Cheilitis

PD-1.1.13.9

11828

q Tingling of foot

PD-1.1.16.23

11882

q Cleft palate

PD-1.1.13.10

11829

q Tingling of hand

PD-1.1.16.24

11883

q Cracked lips

PD-1.1.13.11

11830

q Drooling

PD-1.1.13.12

11831

q Acanthosis nigricans

PD-1.1.17.1

11884

q Dry mucus membranes

PD-1.1.13.13

11832

q Calcinosis

PD-1.1.17.2

11885

q Dysgeusia

PD-1.1.13.14

11833

q Carotenemia

PD-1.1.17.3

11886

q Excessive salivation

PD-1.1.13.15

11834

q Cutaneous xanthoma

PD-1.1.17.4

11887

q Excessive thirst

PD-1.1.13.16

11835

q Decreased skin turgor

PD-1.1.17.5

11888

q Gingival hypertrophy

PD-1.1.13.17

11836

q Dermatitis

PD-1.1.17.6

11889

q Gingivitis

PD-1.1.13.18

11837

q Diaper rash

PD-1.1.17.7

11890

q Halitosis

PD-1.1.13.19

11838

q Dry skin

PD-1.1.17.8

11891

q Hemorrhagic gingivitis

PD-1.1.13.20

11839

q Ecchymosis

PD-1.1.17.9

11892

q Hypogeusia

PD-1.1.13.21

11840

q Erythema

PD-1.1.17.10

11893

q Ketotic breath

PD-1.1.13.22

11841

q Eczema

PD-1.1.17.11

11894

q Micrognathia

PD-1.1.13.23

11842

q Flushing

PD-1.1.17.12

11895

q Swollen gums

PD-1.1.13.24

11843

q Hirsutism

PD-1.1.17.13

11896

q Oral candidiasis

PD-1.1.13.25

11844

q Hyperpigmentation of skin

PD-1.1.17.14

11897

q Oral lesion

PD-1.1.13.26

11845

q Impaired skin integrity

PD-1.1.17.15

11898

q Parotid swelling

PD-1.1.13.27

11846

q Jaundice

PD-1.1.17.16

11899

q Poor oral hygiene

PD-1.1.13.28

11847

q Keratinization of skin

PD-1.1.17.17

11900

q Retains food in mouth

PD-1.1.13.29

11848

q Pale complexion

PD-1.1.17.18

11901

q Stomatitis

PD-1.1.13.30

11849

q Peeling skin

PD-1.1.17.19

11902

q Uremic breath

PD-1.1.13.31

11850

q Petechiae

PD-1.1.17.20

11903

q Impaired wound healing

PD-1.1.17.21

11904

q Skin (17)

q Muscles (14) Muscle atrophy

PD-1.1.14.1

11852

q Pressure injury of ankles

PD-1.1.17.22

11905

Muscle contracture

PD-1.1.14.2

11853

q Pressure injury of back

PD-1.1.17.23

11906

Muscle cramp

PD-1.1.14.3

11854

q Pressure injury of breast

PD-1.1.17.24

11907

Muscle pain

PD-1.1.14.4

11855

q Pressure injury of buttock

PD-1.1.17.25

11908

Muscle weakness

PD-1.1.14.5

11856

q Pressure injury of dorsum of foot

PD-1.1.17.26

11909

Quadriceps muscle wasting

PD-1.1.14.6

11857

q Pressure injury of elbow

PD-1.1.17.27

11910

8 Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.

Nutrition Assessment and Monitoring and Evaluation Terminology NCPT Code

ANDUID

NCPT Code

ANDUID

q Pressure injury of head

PD-1.1.17.28

11911

q Lesion of the tongue

PD-1.1.20.8

11966

q Pressure injury of heel

PD-1.1.17.29

11912

q Strawberry tongue

PD-1.1.20.9

11967

q Pressure injury of hip

PD-1.1.17.30

11913

q Macroglossia

PD-1.1.20.10

11968

q Pressure injury of knee

PD-1.1.17.31

11914

q Short frenulum of tongue

PD-1.1.20.11

11969

q Pressure injury of natal cleft

PD-1.1.17.32

11915

q Split frenulum of tongue

PD-1.1.20.12

11970

q Pressure injury of shoulder

PD-1.1.17.33

11916

PD-1.1.21

10370

q Pressure injury stage 1

PD-1.1.17.34

11917

q Pressure injury stage 2

PD-1.1.17.35

11918

CLIENT HISTORY (CH)

q Pressure injury stage 3

PD-1.1.17.36

11919

Current and past information related to personal, medical, family, and social history.

q Pressure injury stage 4

PD-1.1.17.37

11920

Personal History (1)

q Pruritus of the skin

PD-1.1.17.38

11921

q Psoriasis

PD-1.1.17.39

11922

General patient/client information such as age, gender, sex, race, ethnicity, language, education, and role in family.

q Scaling skin

PD-1.1.17.40

11923

Personal data (1.1)

q Seborrheic dermatitis

PD-1.1.17.41

11924

q Age

CH-1.1.1

10374

q Skin rash

PD-1.1.17.42

11925

q Gender

CH-1.1.2

10375

q Stasis ulcer

PD-1.1.17.43

11926

q Sex

CH-1.1.3

11138

q Yellow skin

PD-1.1.17.44

11927

q Race

CH-1.1.4

11139

q Ethnicity

CH-1.1.5

11140

 

q Vital signs

q Teeth (18) q Baby bottle tooth decay

PD-1.1.18.1

11929

q Language

CH-1.1.6

10377

q Broken denture

PD-1.1.18.2

11930

q Literacy factors

CH-1.1.7

10378

q Broken teeth

PD-1.1.18.3

11931

q Education

CH-1.1.8

10379

q Dental caries

PD-1.1.18.4

11932

q Role in family

CH-1.1.9

10380

q Dental fluorosis

PD-1.1.18.5

11933

q Tobacco use

CH-1.1.10

10381

q Dental plaque

PD-1.1.18.6

11934

q Physical disability

CH-1.1.11

10382

q Denture loose

PD-1.1.18.7

11935

q Mobility

CH-1.1.12

10383

q Denture lost

PD-1.1.18.8

11936

Patient/Client/Family Medical/Health History (2)

q Denture present

PD-1.1.18.9

11937

q Edentulous

PD-1.1.18.10

11938

Patient/client or family disease states, conditions, and illnesses that may have nutritional impact.

q Erosion of teeth

PD-1.1.18.11

11939

Patient/client OR family nutrition-oriented medical/health history (2.1)

q Impaired dentition

PD-1.1.18.12

11940

Specify issue(s) and whether it is patient/client history (P) or family history (F)

q Ill fitting denture

PD-1.1.18.13

11941

q Mottling of enamel

PD-1.1.18.14

11942

q Partially edentulous mandible

PD-1.1.18.15

11943

q Partially edentulous maxilla

PD-1.1.18.16

11944

q Rampant dental caries

PD-1.1.18.17

11945

q Patient/client chief nutrition complaint

CH-2.1.1

10386

CH-2.1.2

10387

CH-2.1.3

10388

CH-2.1.4

10389

CH-2.1.5

10390

CH-2.1.6

10391

CH-2.1.7

10392

CH-2.1.8

10393

CH-2.1.9

10394

CH-2.1.10

10395

CH-2.1.11

10396

CH-2.1.12

10397

(specify) __________________________ P or F q Cardiovascular (specify) __________________________ P or F q Endocrine/metabolism

q Throat and swallowing (19)

(specify) __________________________ P or F

q Choking during swallowing

PD-1.1.19.1

11947

q Cough

PD-1.1.19.2

11948

q Dysphagia

PD-1.1.19.3

11949

q Esophageal lesion

PD-1.1.19.4

11950

q Food sticks on swallowing

PD-1.1.19.5

11951

q Gagging

PD-1.1.19.6

11952

q Hoarse voice

PD-1.1.19.7

11953

q Hypoactive gag reflex

PD-1.1.19.8

11954

q Odynophagia

PD-1.1.19.9

11955

q Swallow impairment

PD-1.1.19.10

11956

q Suck, swallow, breath incoordination

PD-1.1.19.11

11957

q Excretory (specify) __________________________ P or F q Gastrointestinal (specify) __________________________ P or F q Gynecological (specify) __________________________ P or F q Hematology/oncology (specify) __________________________ P or F q Immune (e.g., food allergies) (specify) __________________________ P or F q Integumentary

q Tongue (20)

(specify) __________________________ P or F

q Atrophy of tongue papillae

PD-1.1.20.1

11959

q Beefy red tongue

PD-1.1.20.2

11960

q Difficulty moving tongue

PD-1.1.20.3

11961

q Dry tongue

PD-1.1.20.4

11962

q Glossitis

PD-1.1.20.5

11963

q Glossodynia

PD-1.1.20.6

11964

q Hypertrophy of tongue papillae

PD-1.1.20.7

11965

q Musculoskeletal (specify) __________________________ P or F q Neurological (specify) __________________________ P or F q Psychological (specify) __________________________ P or F

9 Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.

Nutrition Assessment and Monitoring and Evaluation Terminology NCPT Code

ANDUID

CH-2.1.13

10398

CH-2.1.14

10399

NCPT Code

ANDUID

  q Respiratory

Estimated fiber needs (2.4)

(specify) __________________________ P or F q Other (specify) __________________________ P or F

Treatments/therapy (2.2)

CH-2.2.1 CH-2.2.2

10402

CH-2.2.3

10404

10436

q Method for estimating needs

CS-2.4.3

10437

q Total fluid estimated needs

CS-3.1.1

10440

q Method for estimating needs

CS-3.1.2

10441

Micronutrient Needs (4) Estimated vitamin needs (4.1)

(specify) _______________________________ q Palliative/end-of-life care

10435

CS-2.4.2

Estimated fluid needs (3.1)

10401

(specify) _______________________________ q Surgical treatment

CS-2.4.1

q Type of fiber needed Fluid Needs (3)

Documented medical or surgical treatments that may impact nutritional status of the patient q Medical treatment/therapy

q Total fiber estimated needs

q A (1)

10444

q C (2)

10445

Social History (3)

q D (3)

10446

Patient/client socioeconomic status, housing situation, medical support, and involvement in social groups.

q E (4)

10447

q K (5)

10448

q Thiamin (6)

10449

q Riboflavin (7)

10450

q Niacin (8)

10451

q Folate (9)

10452

q B6 (10)

10453

q B12 (11)

10454

q Pantothenic acid (12)

10455

q Biotin (13)

10456

q Method for estimating needs (14)

10458

(specify) _______________________________

Social history (3.1) q Socioeconomic factors

CH-3.1.1

10407

CH-3.1.2

10408

(specify) _______________________________ q Living/housing situation (specify) _______________________________ q Domestic issues

CH-3.1.3

10409

CH-3.1.4

10410

(specify) _______________________________ q Social and medical support (specify) _______________________________ q Geographic location of home

CH-3.1.5

10411

CH-3.1.6

10412

(specify) _______________________________ q Occupation

Estimated mineral needs (4.2)

q Calcium (1)

10460

q Chloride (2)

10461

q Iron (3)

10462

q Magnesium (4)

10463

q Potassium (5)

10464

q Phosphorus (6)

10465

q Sodium (7)

10466

q Zinc (8)

10467

q Sulfate (9)

10469

q Fluoride (10)

10470

q Copper (11)

10471

q Iodine (12)

10473

Macronutrient Needs (2)

q Selenium (13)

10474

Estimated fat needs (2.1)

q Manganese (14)

10475

(specify) _______________________________ q Religion

CH-3.1.7

10413

CH-3.1.8

10414

(specify) _______________________________ q History of recent crisis (specify) _______________________________ q Daily stress level

CH-3.1.9

10415

(specify) _______________________________

COMPARATIVE STANDARDS (CS) Energy Needs (1) Estimated energy needs (1.1) q Total energy estimated needs

CS-1.1.1

10419

q Method for estimating needs

CS-1.1.2

10420

q Total fat estimated needs

CS-2.1.1

10423

q Chromium (15)

10476

q Type of fat needed

CS-2.1.2

10424

q Molybdenum (16)

10477

q Method for estimating needs

CS-2.1.3

10425

q Boron (17)

10478

q Cobalt (18)

10479

q Total protein estimated needs

CS-2.2.1

10427

q Method for estimating needs (19)

10480

q Type of protein needed

CS-2.2.2

10428

Weight and Growth Recommendation (5)

q Method for estimating needs

CS-2.2.3

10429

Recommended body weight/body mass Index/growth (5.1)

q Ideal/reference body weight (IBW)

CS-5.1.1

10483

q Total carbohydrate estimated needs

CS-2.3.1

10431

q Recommended body mass index (BMI)

CS-5.1.2

10484

q Type of carbohydrate needed

CS-2.3.2

10432

q Desired growth pattern

CS-5.1.3

10485

q Method for estimating needs

CS-2.3.3

10433

Estimated protein needs (2.2)

Estimated carbohydrate needs (2.3)

  10

Nutrition Care Process Terminology (eNCPT), 2015 Edition. Copyright 2015 Academy of Nutrition and Dietetics.