Effective nutrition and dietetics care delivery hinges on a structured approach that ensures consistency, quality, and personalized care. This chapter introduces the Nutrition Care Process (NCP) Model and its associated Nutrition Care Process Terminology (NCPT) , a pivotal framework and standardized language designed to help professionals deliver tailored nutrition and dietetics care. The NCP Model and NCPT have been developed and continually refined over years through global collaboration, led by the Academy of Nutrition and Dietetics (referred to as the Academy thereafter), with input from numerous nutrition and dietetic associations around the world.

Additionally, the chapter will introduce the SNOMED CT NCPT Reference Set (or refset) , which further enhances the ability of healthcare professionals to standardize and integrate nutrition and dietetics care into broader clinical systems, supporting interoperability and comprehensive patient care across settings.

The SNOMED CT NCPT Reference Set (release of April 2026) contains the "problems" or nutrition diagnoses, "intervention" terms, and nutrition assessment, monitoring and evaluation terms of NCPT (edition 2020). It is important to emphasize that SNOMED CT is used by many countries where English is not the main language. The Nutrition and Dietetics CRG which has a wide international membership encourages the translation of the SNOMED CT NCPT refset and welcomes updates on translation efforts. Sweden already has a SNOMED CT NCPT refset release containing the diagnostic terms in the Swedish language since November 2024. For more on the translation process of refsets, please see section of this guide.

The Nutrition Care Process Model (NCPM) serves as a framework for nutrition and dietetics professionals engaged in providing nutrition and dietetics care. The NCP Model offers a systematic, evidence-based approach to assessing, diagnosing, planning, implementing, and evaluating nutrition and dietetics care.

Structured around four sequential steps, the NCP Model guides nutrition and dietetics professionals through the process of delivering comprehensive nutrition and dietetics care:

1. Nutrition Assessment and Reassessment : This initial step involves gathering pertinent information about the patient’s nutritional status, dietary habits, health history, social determinants of health (SDOH) and lifestyle factors. Regular reassessment ensures that care plans remain current and responsive to evolving needs. Reassessment is a future assessment that occurs during a follow up interaction with a patient. The reassessment builds on what the assessment raised as initial findings and also may identify new findings that must be addressed as part of continued care.

2. Nutrition Diagnosis : Building upon the assessment findings, nutrition and dietetics professionals identify alterations in the nutritional status of the patient through naming nutrition-related problems and establishing clear, actionable objectives.* Nutrition diagnoses serve as the foundation for developing targeted interventions aimed at resolving the cause (or etiology) and/or contributing factors of the problems and meeting specific nutrition needs and goals.

Through its structured approach, the NCP Model enhances consistency, quality, and description of nutrition/dietetics care and related health outcomes. While care delivery remains individualized to meet the unique needs of those being served, the NCP Model provides a standardized framework for guiding professionals through the delivery process. The structured framework facilitates data aggregation for patient populations and subsequent data analytics, outcomes management and opportunities to research and improve the NCP Model itself.

The entryway to the NCP is via nutrition screening or referral of client or patient. The purpose of the screening and referral system is to identify and refer those who have or are at risk for nutrition problems, and who are appropriate to receive nutrition and dietetics care services as described by the NCP. The nutrition screening process utilizes valid, and reliable screening tools to identify and document nutrition risk. The screening and referral system improves interdisciplinary collaboration among healthcare professionals.

The output of the NCP Model is emphasizing the importance of studying the NCP itself, aggregating data to conduct research and quality improvement initiatives, and calculating/reporting quality indicators like (Electronic Clinical Quality Measures that are currently utilized as far as we know in the United States by the Centers for Medicare and Medicaid Services).

External and professional factors are depicted in the two outer rings to reflect practice settings, health care systems, social systems, and economic environment. The middle ring includes variables that influence quality of practice and include: dietetics knowledge, skills and competencies, critical thinking, collaboration, communication and documentation, evidence-based practice, and code of ethics. The center circle (core) features the patient/population that interacts with the nutrition and dietetics professional and as such the core of the NCPM symbolizes people-centered nutrition care delivery.

*This is an updated definition because V2 standards cite alteration in nutrition status and point to LOINC 75305-3 Nutritional status with synonym nutrition diagnosis.

The NCPT includes a set of terms for each step of the NCP. Nutrition Assessment terms describe observed and measured data that provide evidence about nutrition-related problems or diagnoses. Nutrition Diagnosis terms describe the nutrition problem that nutrition and dietetics professionals are responsible for treating and/or managing. Intervention terms describe planned actions aimed toward resolving nutrition problems and the cause (or etiology) of these problems. The Nutrition Assessment and Monitoring and Evaluation steps share, for the most part, the same terminology. Specifically, Nutrition Assessment terms that describe Client History are not included in the Monitoring and Evaluation terminology because nutrition interventions cannot change a client's history. When terms are used in the Monitoring and Evaluation step, they are used to describe outcomes or expected outcomes relevant to the Nutrition Diagnosis. NCP Terms for each step are organized by Domains. Domains are further organized into Classes and Subclasses. For example, the term Energy Intake falls under the Domain: Food/Nutrition-related History. (Detailed information on the current hierarchical organization of NCPT and term definitions can be found at (log in required).

By employing standardized terminology and coding conventions outlined in NCPT, nutrition and dietetics professionals can ensure consistency, accuracy, and interoperability (automated data exchange) in documenting nutrition and dietetics care data across different electronic health record (EHR) systems. This standardized approach supports improved data quality, enhances communication between healthcare providers, and enables meaningful analysis and research on nutrition and dietetics care outcomes and health outcomes.

The development and adoption of the Nutrition Care Process Terminology (NCPT) have been the result of extensive international collaboration and usage, reflecting a global consensus on the need for standardized documentation and communication of nutrition and dietetics care data.

While vendors may initially question the investment required to integrate NCPT into electronic health record (EHR) systems, understanding its widespread acceptance and the benefits it offers, can illuminate its value.

Nutrition and dietetics professionals stand to benefit significantly from utilizing NCPT, regardless of whether they are already using SNOMED CT or not, as it provides a standardized language for documenting nutrition and dietetics care data. The integration of NCPT with SNOMED CT further enhances its utility, facilitating seamless interoperability and enabling clinicians to leverage the SNOMED CT NCPT refset within the EHR. Even if clinicians are already using SNOMED CT, the NCPT refset offers additional value by providing a curated set of concepts specifically tailored to document nutrition and dietetics care within the Nutrition Care Process, streamlining documentation and ensuring consistency across practices.

This integration not only enhances the quality and efficiency of nutrition and dietetics care delivery but also supports informed clinical decision-making and research efforts aimed at improving patient outcomes.

For systems who use NCPT as an interface terminology and pursue to enable SNOMED CT, the Academy of Nutrition and Dietetics maintains mappings from NCPT to SNOMED CT ( , institutional level log in required).

In summary, the NCP Model and NCPT represent foundational tools for guiding nutrition and dietetics professionals in delivering evidence-based, personalized nutrition and dietetics care including but not limited to medical nutrition therapy. By adopting tools like these, healthcare organizations can enhance the quality, consistency, and effectiveness of nutrition and dietetics care delivery, ultimately promoting better health outcomes for individuals and communities alike. Wide adoption also facilitates communication, data exchange and aggregation among health delivery systems, making the accumulation of big data and advanced analyses possible.

Background

Most nutrition and dietetics professionals work in settings where they treat people (either clients or patients or groups) through medical nutrition therapy (MNT) to manage or prevent nutrition-related disease.

The Nutrition Care Process (NCP) is a concise framework model for professionals, such as dietitians, who provide nutrition and dietetics care. The NCP embraces people-centered care and has been evolving since 2003 to become the international standard for nutrition and dietetics care delivery. The NCP encourages the use of standardized terminology. Standardized terminology is necessary for data to follow the patient or client across settings when different electronic health records (EHR) systems are involved (e.g. all data from an acute care unit is transmitted as documented to a community care setting).

The documentation and exchange of coded nutrition and dietetics care data vary across EHRs due to a lack of standardized terminology and inconsistent implementation practices, making interoperability and continuity of care challenging.

The lack of interoperability limits the aggregation of nutrition and dietetics care data for informed clinical decision support. It also hinders the ability to research the effectiveness of nutrition and dietetics care and resulting health outcomes. The documentation of nutrition and dietetics care data must be clearly defined in EHRs to support patient health, safety and a comprehensive health record.

Entry points to the NCP (i.e. initiation of nutrition and dietetics care by a nutrition and dietetics professional) are typically screening and/or referral systems. The NCP framework (or NCP) for nutrition and dietetics care was designed and approved by the Academy of Nutrition and Dietetics in 2003. Since then, the Academy of Nutrition and Dietetics has collaborated with many international nutrition and dietetics associations to revise, evolve and adopt the NCP in its current form. Also, alternate iterations of the NCP have since been used and exist. From an international perspective, this demonstrates and solidifies the usability and adaptability of the NCP going into the future.

In the NCP, there are four steps:

• Nutrition Assessment and Reassessment

• Nutrition Diagnosis

• Nutrition Intervention

• Nutrition Monitoring and Evaluation

Nutrition and dietetics professionals frequently use the Nutrition Care Process Terminology (NCPT) to communicate the Nutrition Care Process. The NCPT is a standardized terminology that complements the NCP, communicates the functions of nutrition and dietetics professionals, and facilitates research on the outcomes of nutrition and dietetics care.

In its majority, the NCPT (edition 2020) has been integrated into SNOMED CT as a result of many international nutrition and dietetics organizations working collaboratively with the Academy of Nutrition and Dietetics and SNOMED International. The first iteration of SNOMED CT's NCPT reference set (also called refset*) (released in April 2024) contained the concepts that document Nutrition Diagnosis in the NCP (166 concepts), (). The second SNOMED CT NCPT Reference Set (released in April 2025) contained updated nutrition problems and the addition of nutrition intervention terms mapped to SNOMED CT, (2025 ). This third and current update completes the currently planned content inclusion to the reference set. The April 2026 version of the reference set contains a total of 1115 concepts, see the . Going forward, the reference set will be maintained on an annual basis.

In a healthcare environment that evolves rapidly, the vision for the NCP and NCPT is to make possible communication within and across healthcare systems for quality care and outcomes research. Implementation strategies should include the development of resources like the present implementation guide, education and training, leadership support, and change-management approaches.

Standards Development Organizations (SDOs), like Health Level Seven International (HL7), in collaboration with the Academy of Nutrition and Dietetics have developed standards and provided guidance to assist implementers, however specific guidance in using and implementing SNOMED CT in the context of nutrition and dietetics care is limited. The present implementation guide fills this gap.

The objective of the SNOMED CT implementation guide for Nutrition Care Process Terminology (NCPT) is to support standardized practices and terminology for documenting nutrition and dietetics care data within Electronic Health Records (EHRs), specifically describing the four steps of the Nutrition Care Process (NCP) Model:

• Nutrition Assessment and Reassessment

• Nutrition Diagnosis

• Nutrition Intervention

• Nutrition Monitoring and Evaluation

This guide aims to improve consistency, and quality of nutrition and dietetics care data documentation and exchange across electronic systems (interoperability), facilitating informed clinical decision support, research on the efficacy of nutrition and dietetics care, and enhancing patient health, safety, and comprehensive health record management.

The guide operationalizes the utilization of the SNOMED CT NCPT (Nutrition Care Process Terminology) reference set to enhance the quality of documentation and care in this vital domain.

SNOMED International has created a draft demonstration tool to showcase the principles and techniques elucidated in the guide. Please access this here:

The scope of the work presented in this guide includes:

1. Review standards on nutrition and dietetics care

2. Analyze relevant information models

   1. Review existing information models that are in scope, with emphasis on HL7® Fast Healthcare Interoperability Resources (FHIR®) that have gained wide adoption in recent years

*The word "refset" is a combination of the two words "reference set". Reference sets are essentially published subsets of the full SNOMED CT. The International Release of SNOMED CT contains over 370,000 concepts. It is understandable that not all users need to use all of these. A practical way to easily identify and use concepts by practice area is by establishing refsets that can be used by related healthcare professionals. This reference set mechanism provides a standardized approach to refer to a subset of SNOMED CT. Here, the NCPT SNOMED refset can be very useful to nutrition and dietetics professionals who provide nutrition and dietetics care. For more on refsets see:

**The words "value set" means a group of valid concepts or expressions intended to constrain the permissible content for a particular use (e.g. a value set for malnutrition will be a defined list of concepts used to document the different types of malnutrition). For more information see: from the US.

SNOMED CT is a comprehensive, multilingual clinical terminology that can be used to standardize and improve the quality of data related to nutrition and dietetics care. This guide is targeted at the various stakeholders involved with the implementation of SNOMED CT:

• who are seeking uniform, clear best practices for documenting nutrition and dietetics care, and understanding how SNOMED CT can be applied in this domain.

• Clinicians and other healthcare professionals (such as hospital administrators and managers) who are interested in understanding how SNOMED CT can support the clinical needs for data collection and acquisition within the field of nutrition and dietetics; and how SNOMED CT can facilitate communication within a collaborative team where the client is included.

• Quality measure developers and those implementing quality initiatives who are reporting nutrition and dietetics care data and/or examining the impact of nutrition and dietetics interventions on healthcare outcomes.

This SNOMED CT Implementation guide and the underlying work have been developed by the . The Clinical Reference Group (CRG) is composed of experts in the field of nutrition and dietetics providing input from the community of practice on the development, maintenance, and use of SNOMED CT in this specific domain. The CRG members have been instrumental in the development of this guide, providing their expertise, knowledge, and experience to ensure that it is accurate, up-to-date, and relevant to the needs of its intended audience. Their dedication and hard work have made this guide possible and SNOMED International is grateful for their contributions. This guide is a product of SNOMED International's ongoing commitment to improving healthcare through the use of high-quality, standardized clinical terminologies.

Main Contributors

Acknowledgement to the Academy of Nutrition and Dietetics ()

Individuals:

• Dr. Constantina Papoutsakis, Chair, Nutrition and Dietetics Clinical Reference Group, Academy of Nutrition and Dietetics

• William Swan, Past Chair, Nutrition Care Process Research Outcomes Committee, Academy of Nutrition and Dietetics, USA

• Dr. Angela Vivanti, Past Chair, Nutrition Care Process Research Outcomes Committee, Academy of Nutrition and Dietetics, Princess Alexandra Hospital, Australia

This SNOMED CT Implementation Guide is designed to provide guidance for the use of SNOMED CT within the domain of nutrition and dietetics care. The guide is organized into the following main chapters:

• Introduction - This chapter provides a background on the guide, including the objectives, scope, and target audience.

• What is NCP and NCPT? - This chapter provides basic information on the Nutrition Care Process (NCP) Model (NCPM-the graphic depiction of the NCP) and NCP Terminology (NCPT).

• Clinical Use Cases - This chapter describes the key use cases that have motivated the creation of this guide and explains scenarios where implementation of SNOMED CT within this domain is needed.

In addition, a number of appendices present additional information and insights into the terms used in this document, and references to relevant resources.

This SNOMED CT Implementation guide represents the culmination of work started by the Implementation SIG (SIG means Special Interest Group) in 2014 and continued by the starting in 2023.

We welcome feedback from readers on the guide and encourage them to share their insights and experiences with us. Your comments and suggestions will help us improve the content of the guide and ensure that it is relevant and useful to those who use it. We will review any feedback received and make updates to the guide as needed.

We appreciate your interest in this guide and thank you for your contributions to the improvement of healthcare through the use of high-quality, standardized clinical terminologies like SNOMED CT. Please raise any comments to this document via the feedback button (At the bottom of the page).

REFERENCES

Lloyd L, Swan WI, Jent S, Vivanti A, Pertel DG. Worldwide Release of SNOMED CT Nutrition Care Process Terminology Problem List. J Acad Nutr Diet. 2024 Apr;124(4):531-534.

Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, Beck Howarter K, Papoutsakis C. Nutrition Care Process and Model Update: Toward Realizing People-Centered Care and Outcomes Management. J Acad Nutr Diet. 2017 Dec;117:2003-14.

Swan WI, Pertel DG, Hotson B, Lloyd L, Orrevall Y, Trostler N, Vivanti A, Howarter KB, Papoutsakis C. Nutrition Care Process (NCP) Update Part 2: Developing and Using the NCP Terminology to Demonstrate Efficacy of Nutrition Care and Related Outcomes. J Acad Nutr Diet. 2019 May;119:840-55.

The SNOMED CT Implementation Guide for Nutrition Care Process Terminology (NCPT) provides practical guidance for documenting nutrition and dietetics care using standardized SNOMED CT concepts. Aligned with the internationally recognized Nutrition Care Process (NCP), this guide supports consistent, interoperable data capture across electronic health systems to improve care quality, enable clinical decision support, and facilitate outcomes research.

Please click the button to get a pdf version of the April 2026 version of this Implementation Guide.

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History

To facilitate the development of nutrition-related content in SNOMED CT, the NCPT Clinical Project Group was established, bringing together nutrition and dietetics professionals across several continents. This group played a pivotal role in reviewing, validating, and authoring content directly into the SNOMED CT International Release with support from SNOMED International authors. The work of the project group, which took place between 2017 and 2023, concluded with the integration of NCPT (Nutrition Care Process Terminology, Edition 2020) into SNOMED CT.

The responsibility for maintaining nutrition and dietetics content within SNOMED CT has since, transitioned to the Nutrition and Dietetics Clinical Resource Group (CRG). This group is now tasked with overseeing the management of nutrition-related concepts, maintaining the SNOMED CT NCPT reference set, and leading quality improvement projects in collaboration with SNOMED International. The Academy of Nutrition and Dietetics continues to provide stewardship through dedicating staff support.

Benefits of SNOMED CT

When clinical concepts are modeled using a set of rules (these rules are explained in the SNOMED CT Editorial Guide), this allows for consistent representation of clinical information in electronic health records (EHRs). Thus, good modeling enhances the quality of the data. Also, modeling of concepts offers the necessary infrastructure to carry out data analytics, collapse, or parse different sets of data. This means that data can be analyzed with different levels of granularity, across different settings, and reused by many for different objectives. (for more information on data analysis with SNOMED CT, please refer to: Data Analytics with SNOMED CT and Data Analytics Tooling)

Key Benefits of High-Quality Clinical Concept Modeling

High-quality modeling of clinical concepts is crucial for ensuring data quality and maximizing the utility of health information. Effective modeling supports the automation of processes and the generation of knowledge at various levels, from individual healthcare services to institutional, regional, national, and international systems.

• Population Analytics : With SNOMED CT, healthcare organizations can analyze population data to identify patterns and trends across patient groups. This enables the detection of shifts in the prevalence of clinical issues (such as nutrition-related problems), procedures, and interventions over time, helping to inform public health initiatives, resource allocation, and policy development.

• Clinical Decision Support Systems : SNOMED CT serves as a foundation for clinical decision support, enabling systems to provide timely, evidence-based recommendations. By standardizing data, it also facilitates accurate laboratory reporting and registry tracking and reporting, improving the precision and consistency of clinical decision-making and documentation.

By modeling clinical concepts with precision, SNOMED CT not only enhances data quality but also empowers healthcare systems to harness data for deeper insights, improved decision-making, and more equitable, coordinated care globally.

This chapter provides a comprehensive overview of SNOMED CT content specific to the Nutrition Care Process Terminology (NCPT). The objective of the following sections is to explain how SNOMED CT concepts relevant to the Nutrition Care Process (NCP) are modeled within the SNOMED CT framework.

It is important to note that there is no single, unified hierarchy dedicated solely to “nutrition content” within SNOMED CT. Instead, relevant content is distributed across various sub-hierarchies according to broader domains, such as Procedures , Clinical Findings , and others. This division ensures that nutrition-related concepts are aligned with the overarching structure of SNOMED CT while remaining accessible within the appropriate contexts.

To aid understanding and interpretation, each page of this chapter will introduce relevant content, along with explanations of its modeling approach, attributes, and examples. This layout is designed to help readers navigate and utilize SNOMED CT content for NCPT effectively, with practical examples that demonstrate the structure and utility of each concept within clinical documentation and workflows.

HL7 Domain Analysis Model for Nutrition Care

The HL7 Domain Analysis Model: Nutrition Care, Release 3 Standard (December 2022-2024) outlines a comprehensive framework for implementing and standardizing nutrition care processes in healthcare environments. Developed by Health Level Seven International (HL7) in collaboration with the Academy of Nutrition and Dietetics, this document focuses on enhancing the integration and interoperability of nutrition-related data within Electronic Health Records (EHRs) and other health information systems.

The model builds on the Nutrition Care Process (NCP), which standardizes the steps of Nutrition Assessment, Diagnosis, Intervention, and Monitoring/Evaluation to ensure consistent and high-quality nutrition care. This framework emphasizes patient-centered care, quality improvement, and the effective communication of nutrition orders and assessments across multidisciplinary healthcare teams.

The HL7 Domain Analysis Model elaborates on the specific workflows and data elements necessary for effective documentation, providing practical use cases such as diet ordering, food allergy management, and tailored nutrition interventions.

Logical Model for Nutrition Care Records

This page adapts the HL7 Domain Analysis Model (DAM) for Nutrition Care, and provides a Logical Model for the Nutrition Care Process (NCP), which serves as a technology-agnostic common reference , designed to be adaptable to specific implementation requirements while highlighting where terminology bindings to SNOMED CT can be applied. By outlining essential entities, such as Patient , Practitioner/Dietitian , Assessment , Diagnosis , Intervention , and Monitoring/Evaluation , and their relationships, this model aims to support consistent and organized documentation across the entire care process, provided it is implemented correctly.

The Nutrition Care Records Model outlines a comprehensive framework for managing nutrition care, highlighting key entities' roles and interactions to support patient-centered outcomes.

• Patient is the central entity, representing the individual who receives nutrition care. The patient is linked to various elements of the care process, including nutrition assessments, diet orders, and monitoring and evaluation activities.

• Dietitian plays a pivotal role throughout the care process. Dietitians perform nutrition assessments, establish nutrition diagnoses, implement appropriate interventions, develop care plans, and monitor the patient’s progress. They ensure that the nutrition care provided aligns with evidence-based practices and patient-specific needs.

  • The DAM utilizes the term “Practitioner” per HL7. This aligns with and helps to also be more inclusive of the NDTR (Nutrition Dietetic Technician, Registered) role in the United States.

The provided ER (Entity-Relationship) diagram for Nutrition Care Records illustrates the relationships between key entities involved in nutrition care and how they interact at the data storage level. It is important to note that this diagram does not represent a clinical workflow. Instead, it demonstrates how data collected during a clinical workflow can be structured and associated within a database. This model has been developed as part of this guide to highlight the key entities relevant to nutrition care and to indicate where the SNOMED CT NCPT reference set can be utilized.

Nutrition Diagnosis Value Sets

These following bindings ensure that the FHIR resources effectively capture nutrition diagnosis information using standardized SNOMED CT terminology, promoting interoperability and accurate data exchange across healthcare systems.

The following value sets can be used as alternative bindings to represent nutrition diagnosis data. The “Nutrition Diagnosis Grouping” value set, stewarded by the Academy of Nutrition and Dietetics and available via the Value Set Authority Center (VSAC) at the National Library of Medicine (NLM), contains 167 concepts and can be accessed . Another value set, the “Nutrition Focused Physical Findings Grouping,” also stewarded by the Academy of Nutrition and Dietetics, includes 372 concepts and is accessible . These value sets enable precise and standardized documentation of nutrition-related diagnoses and physical findings.

Implementing the SNOMED CT Nutrition Care Process Terminology (NCPT) Reference Set (Refset) within a clinical system can significantly improve the quality, consistency, and interoperability of nutrition documentation. This page outlines general approaches and considerations for successfully integrating the NCPT Refset into clinical workflows. These approaches will support healthcare professionals, technical implementers, and informatics teams in aligning documentation with the Nutrition Care Process (NCP) model.

Key Approaches for Implementing the NCPT Reference Set

The flowchart below illustrates key considerations and decisions involved in selecting the optimal approach for implementing the NCPT. Detailed descriptions of each approach are provided below.

Mapping

Mapping the NCPT Refset to existing local terminology is a common and practical starting point for implementation. By aligning SNOMED CT concepts within the NCPT Refset to equivalent or related terms used in the clinical system, mapping allows for accurate representation of nutrition-specific concepts without requiring extensive changes to existing systems.

Recommendation

Collaborate with clinical experts to ensure mappings accurately reflect the intended meanings within the nutrition and dietetics domain. SNOMED International offers a free online mapping service, Snap2SNOMED, which can be used to efficiently map local codes to SNOMED CT.

Extracting a Plain List of Refset Members for Specific Contexts

In certain contexts, such as documenting diagnoses, interventions, or outcomes, it may be beneficial to extract a plain list of relevant NCPT Refset members. This approach enables easy access to the specific concepts needed for different stages of the Nutrition Care Process without overloading the system with unrelated terms.

For each concept, extract its unique identifier, terms, and domain (e.g., diagnosis, intervention, monitoring) to create a streamlined list that aligns with your specific implementation needs. The is a useful tool for this task, allowing efficient extraction of relevant SNOMED CT concepts directly from the terminology hierarchy. Use the bindings specified in General Terminology Bindings to determine the relevant SNOMED CT areas and subhierarchies for each data element, ensuring precise alignment with the appropriate SNOMED CT concepts. For this approach, it is important that you utilize the latest version of SNOMED CT and the NCPT reference set.

SNOMED CT is organized hierarchically, allowing for flexible navigation from broad categories (e.g., body systems or clinical findings) down to specific details (e.g., particular conditions or interventions). Implementers can utilize these hierarchies to contextualize NCPT concepts, enhance search functionality, and streamline data entry by directing clinicians to the most appropriate concept level.

Refer to the bindings specified in to identify the relevant SNOMED CT areas and subhierarchies for each data element. These bindings will help ensure accurate alignment with the appropriate SNOMED CT concepts. For this approach, it is important that you utilize the latest version of SNOMED CT and the NCPT reference set, as described in .

Using a terminology server can be a powerful way to manage, update, and integrate SNOMED CT concepts, including the NCPT Refset, within a clinical system. Terminology servers provide real-time access to SNOMED CT and can support dynamic updates as new versions of the terminology become available, enhancing both usability and long-term system maintenance.

Terminology servers offer centralized management of terms and facilitate seamless interoperability, especially when sharing data across systems or institutions.

Engage with a technical team experienced in terminology servers and FHIR terminology services (FHIR TS) to ensure proper configuration, integration, and maintenance. Their expertise will help optimize server performance, enable seamless updates, and support interoperability across clinical applications. For this approach, it is important that you utilize the latest version of SNOMED CT and the NCPT reference set, as described in .

We recommend following these fundamental steps to ensure a successful implementation of the NCPT Refset within SNOMED CT. Begin by engaging key stakeholders and assessing system capabilities, then set clear goals and consider starting with a pilot project. Providing user training on the Refset’s purpose and benefits will further support effective integration into clinical practice.

Engage Relevant Stakeholders

Begin by reaching out to your SNOMED CT National Release Center (NRC) or SNOMED International representative. They can offer valuable resources and guidance on accessing and implementing the NCPT Refset, ensuring alignment with regional and global standards.

Review Existing System Capabilities

Evaluate your current clinical information system’s capabilities, focusing on SNOMED CT compatibility, terminology mapping tools, and integration with a terminology server. Understanding system readiness helps identify any technical adjustments needed for successful implementation.

Set Clear Goals for Implementation

Define specific use cases and desired outcomes for the NCPT Refset, such as improved documentation consistency, enhanced clinical decision support, or interoperability with external systems. Clear goals will help guide the project scope and implementation strategy.

Develop a Pilot Project

Initiate a pilot project in a focused area, such as nutritional diagnosis or intervention. Starting small allows for the testing and refinement of workflows and user interactions, providing valuable insights before scaling to a full implementation.

Training and Education

Conduct training for clinical users, particularly nutrition and dietetics professionals, to ensure they understand the NCPT Refset’s purpose and benefits within SNOMED CT. Providing hands-on experience builds confidence and ensures that staff are well-prepared to use the Refset effectively in their practice.

For additional guidance, technical resources, or support with the NCPT Refset implementation, consider reaching out to:

• National Release Center (NRC): snomed.org/members

• Nutrition and Dietetics Clinical Reference Group (CRG): Participate in discussions or obtain updates related to NCPT within SNOMED CT by joining the Nutrition and Dietetics CRG.

• SNOMED International Implementation Support Team:

Nutrition Assessment involves collecting and analyzing data to identify nutrition-related issues.

Nutrition Assessment Data and Associated FHIR Resources

Several FHIR resources can represent different aspects of the assessment:

Content and Modeling

• Main hierarchies

  • Terminology for Nutrition Monitoring and Evaluation is predominantly but not exclusively from the Observable Entity hierarchy, but also from the Clinical Finding hierarchy, which encompass questions, outcomes, and indicators relevant to evaluating nutrition interventions and goals.

  • The content is modeled in alignment with these previously described hierarchies

• Templates

  • As part of the content development process, authoring templates were created to support future content additions and quality assurance of existing and new content in this area. The templates described in the assessment and reassessment section are also applicable to monitoring and evaluation.

This will also include concepts from Nutrition Assessment and Reassessment section with some additional examples given here. With the exception of historical assessment content, Nutrition Assessment and Reassessment concepts are modified to achieve nutrition care goals and track nutrition care progress in the Nutrition Monitoring and Evaluation step of the NCP.

Demonstration Video

The following video shows how to verify if a given concept is a member of the NCPT reference set using the SNOMED International SNOMED CT Browser. You can access the browser at browser.snomedtools.org.

Step-by-Step Instructions

Explore how to verify if a concept is part of the NCPT reference set using the SNOMED International SNOMED CT Browser. You can access the browser at browser.snomedtools.org.

1. Open the SNOMED CT Browser ()

2. Click "Go browsing...International Derivatives"

3. Perform a search for a concept of interest.

Fill in a search term matching the concept you are looking for.

4. Select the concept of interest

Click on the concept, so that its details appear in the Summary section

5. Click "Refsets"

Select the "Refsets" tab

If you see the concept |Nutrition Care Process Terminology reference set| in the list of Simple Refsets Memberships, this means that the selected concept is included in the reference set.

As you can see here, when selecting the concept 414916001 |Obesity (disorder)|, this is part of the reference set.

Try to search for and select the concept

Click on "Refsets"

As you can see, the |Nutrition Care Process Terminology reference set| does not appear in the list of Simple Refsets Memberships, indicating that the selected concept is NOT part of the reference set.

Implementing the NCPT reference set and following the recommendations in this guide do not require adherence to any specific clinical guidelines. Instead, this guide is designed to support flexible application, allowing nutrition assessments, interventions, and care plans to be tailored to the diverse practices, standards, and needs found across healthcare settings. Clinical guidelines and care protocols are inherently context-dependent, and practices may vary across different organizations, regions, and countries. As such, this guide does not prescribe or recommend any particular clinical guidelines, recognizing that suitable approaches may differ based on local and organizational requirements.

Clinical guidelines , also known as “clinical practice guidelines,” are “statements that provide recommendations intended to optimize patient care, informed by a systematic review of evidence and an evaluation of the benefits and risks of alternative care options.” Developed and implemented according to internationally recognized standards, clinical guidelines play an important role in:

• Reducing unwarranted practice variation by providing evidence-based recommendations

When working with the Nutrition Care Process Terminology (NCPT) reference set, it’s essential to have efficient access to the content through various systems, regardless of the technology used.

Clinical applications will access the Reference Set content from the selected terminology repository. The main functional requirements include listing all concepts in the Reference Set, filtering by text search strings, and validating whether a concept is a member of the Reference Set.

This page provides examples of how to interact with the reference set, whether you’re using a FHIR terminology server or a relational database like MySQL.

Accessing the Reference Set from a FHIR Terminology Server

When working with the Nutrition Care Process Terminology (NCPT) reference set, leveraging a FHIR terminology server can simplify access and management.

A FHIR terminology server provides mechanisms to work with the Reference Set as a Value Set. The main operations available are $expand and $validate-code.

FHIR Operations

$expand — Get all members of the reference set

Required:

• A reference set specified by its refsetId, for example:

  1303957004 |Nutrition Care Process Terminology reference set (foundation metadata concept)|

• A list of concept or description IDs

• Option to include additional information about each concept or description

$validate-code — Test if a concept or description is a member of the reference set

Required:

• A reference set specified by its refsetId

• A candidate concept.id

• Returns TRUE if the candidate is a member, FALSE otherwise

These examples use the concept 1303957004 |Nutrition Care Process Terminology reference set (foundation metadata concept)| as the refsetId.

Get all members of the reference set

API Call:

Example:

Alternative using Expression Constraint Language (ECL):

or:

Result:

Returns a JSON representation of the reference set members.

Each concept includes:

• code: the conceptId of the reference set member

• display: the preferred term for the reference set member

Also returns:

• total: the total number of reference set members

Paging Parameters:

• count: limits the number of members returned

• offset: specifies the start position in the results (in multiples of the limit)

Test if a concept is a member of the reference set

API Call:

Example:

Result:

Returns a JSON object with a FHIR Parameters resource, including:

• result: a boolean value (true or false) indicating whether the concept is a member of the reference set

If the Reference Set has been loaded into a relational database using a model that complies with the RF2 specification for tables and column names, the reference set content can be accessed using SQL queries.

SQL Query:

Example:

Result:

Returns the IDs of all the concepts or descriptions that are members of the reference set.

SQL Query:

Example:

Result:

• 0: if the candidate component is not in the reference set

• 1: if the candidate component is a member of the reference set

Some reference sets may include the same component more than once. Any value greater than zero indicates that the component is a member of the reference set.

The NCPT reference set is distributed as an independent derivative package. Using it requires a valid Affiliate License, which can be obtained through national or international channels depending on the user’s location. Understanding the licensing requirements and processes is essential for proper utilization and compliance. For more detailed information on obtaining a license and accessing the NCPT reference set, users should contact their National Release Center or SNOMED International directly.

License to Use SNOMED CT

To access and use the NCPT reference set, users must have a valid Affiliate License for SNOMED CT. SNOMED CT is a globally recognized clinical terminology standard, and its usage is governed by strict licensing agreements to ensure compliance and proper utilization. Licensing ensures that users are authorized to access and implement SNOMED CT in their systems.

Individuals or organizations interested in using SNOMED CT must obtain an Affiliate License through their respective National Release Center (NRC) or via SNOMED International.

More information can be found here: https://www.snomed.org/get-snomed

Countries that are members of SNOMED International have specific licensing arrangements in place for accessing SNOMED CT, including the NCPT reference set.

The following points outline the key aspects of member licensing:

• Member Countries: Member countries have a national licensing arrangement with SNOMED International. Healthcare professionals and organizations within these countries can usually access SNOMED CT through their NRC without additional licensing fees.

• Access via NRCs: National Release Centers are responsible for distributing SNOMED CT within their respective countries. They provide access, support, and updates to licensed users. Users should contact their NRC for specific details on how to access the NCPT reference set.

• Non-Member Countries: In countries that are not members of SNOMED International, individuals and organizations must directly approach SNOMED International to obtain the necessary licenses. This may involve additional costs and compliance with international licensing requirements.

The SNOMED International Member Licensing and Distribution Service (MLDS) facilitates access to the NCPT reference set by providing a centralized platform for distributing SNOMED CT and its related reference sets.

The MLDS simplifies the distribution and licensing process for SNOMED CT, including the NCPT reference set. It is available to users through their National Release Centers (NRCs) in member countries and directly through SNOMED International for users in non-member countries.

• MLDS:

• User Guidance:

Once logged into MLDS, you can access the NCPT release package under ‘SNOMED Releases’, as shown in the example image below. This is also the place where release notes are found.

**

A well-defined information model and appropriate terminology bindings are essential to accurately document the NCP within healthcare systems using SNOMED CT. The information model provides a structured framework for organizing data related to nutrition assessment, diagnosis, intervention, and monitoring. Terminology bindings link this data to standardized SNOMED CT concepts, promoting consistent communication and interoperability across healthcare settings. This approach ensures clear and precise documentation, facilitates data sharing, and supports high-quality, patient-centered nutrition care.

To clarify how the NCP can be implemented in clinical information systems and supported by SNOMED CT, a Logical Model for the NCP is presented. This model serves as a technology-agnostic common reference information model, adaptable to specific implementation needs, and highlights points where terminology bindings to SNOMED CT can be effectively applied.

By establishing these models and bindings, healthcare organizations can achieve precise data recording and effective data use.

In recent years, the integration of HL7® FHIR® with SNOMED CT has gained popularity. Given its wide acceptance and capabilities, HL7 FHIR is the preferred information model in this implementation guide. The following sections provide recommended strategies for integrating SNOMED CT with HL7 FHIR to document the NCP within electronic health records (EHRs).

Other information modeling solutions, such as openEHR, may provide useful archetypes. However, they are not included in this version of the guide due to the lack of widely recognized international models in this area. As progress continues, future updates to the guide may include these frameworks.

This section summarizes the key entities and attributes defined in the Logical Model and indicates where SNOMED CT concepts can be used to represent values.

The Technical Application chapter of the SNOMED CT Implementation Guide for the Nutrition Care Process Terminology (NCPT) Reference Set offers practical guidance for implementing and using the reference set in healthcare systems. It covers topics such as implementation approaches, translation of reference set members, accessing and deploying the NCPT Reference Set, and applying it in clinical workflows.

This chapter provides an overview of the steps needed to integrate the NCPT Reference Set effectively, including working with National Release Centers to align with SNOMED CT standards. By following the guidance, organizations can support standardized nutrition care documentation and improve consistency in nutrition-related data use.

Content and Modeling

• Main hierarchies

  • Terminology for nutrition assessment is predominantly from the Observable Entities hierarchy and includes questions relating to client and food/nutrition-related history, anthropometric measurements, biomedical tests and assessment tools. Also included in nutrition assessment is nutrition focused physical findings from the Clinical Finding hierarchy.

• Key attributes and value ranges

  • A range of attributes are available to represent the properties for concepts in this hierarchy (); however, the key attributes that are used for content in the scope of nutrition assessment and reassessment include:

    • Technique: This attribute links to a concept from the Technique (qualifier value) hierarchy and specifies the observation method, e.g., estimation, measurement.

    • Property: This attribute links to a concept from the Property (qualifier value) hierarchy and specifies the type of feature to be observed, e.g., intake quantity, energy intake.

• Templates

  • As part of the content development process, authoring templates were created to support future content additions and quality assurance of existing and new content in this area.

This template ensures that nutrition assessment concepts are modeled clearly, consistently, and clinically relevant, supporting effective documentation and interoperability in healthcare settings.

Content and Modeling

• Main hierarchies

  • Terminology for nutrition diagnosis is predominantly but not exclusively from the Clini cal Finding hierarchy within SNOMED CT. This hierarchy includes concepts related to nutrition-related health issues, conditions, and diagnoses, such as malnutrition, nutrient deficiencies and imbalances.

• Key Attributes and Value Ranges

  • A range of attributes is available to represent the properties for concepts within this hierarchy (); however, the key attributes relevant for nutrition assessment and diagnosis include:

    • Interprets : This attribute links the diagnosis to an observable entity being assessed or measured. For example, a diagnosis of 'difficulty swallowing ' interprets the observation related to a patient's 'ability to swallow', see the example below. This attribute specifies what aspect of nutrition or health is being interpreted within the context of the diagnosis.

• Templates

  • As part of the content development process, authoring templates were created to support future content additions and quality assurance of existing and new content in this area.

This template ensures that nutrition diagnosis concepts are modeled in a clear, consistent, and clinically relevant manner, supporting effective documentation and interoperability in healthcare settings.

Problems related to intake of energy, nutrients, fluids, bioactive constituents through oral diet or nutrition support.

870404000 |Excessive intake of carbohydrate (finding)|

897491008 |Inadequate intake of protein and/or protein derivative (finding)|

Nutritional findings/problems identified that relate to medical or physical conditions

288939007 |Difficulty swallowing (finding)|

448765001 |Unintentional weight loss (finding)|

Nutritional findings/problems that relate to knowledge, attitudes, beliefs, physical environment, access to food or food safety

1149231004 |Absence of readiness for nutrition behavior change (situation)|

1163267006 |Able to access potable water with difficulty (finding)|

Content and Modeling

• Main hierarchies

  • Terminology for nutrition interventions are represented in the SNOMED CT 386373004 | Nutrition therapy (regime/therapy)| hierarchy to facilitate recording nutrition interventions such as food and/or nutrient delivery, or coordination of nutrition care by a nutrition professional. Counselling interventions are represented in SNOMED in the 441041000124100 |Counseling about nutrition (regime/therapy)| hierarchy

    • Key branches:

      • 386373004 | Nutrition therapy (regime/therapy) |

      • 384760004 |Feeding and dietary regime (regime/therapy)|

      • 61310001 |Nutrition education (procedure)|.

• Key attributes and value ranges

  • A range of attributes are available to represent the properties for concepts in this hierarchy (); however, the key attributes that are used for content in the scope of nutrition assessment and reassessment include:

    • Method: This attribute links to a concept from the Action (qualifier value) hierarchy and specifies the action used to perform the procedure, e.g. education, counselling, administration.
• Templates

  • As part of the content development process authoring, templates were created to support future content additions and quality assurance of existing and new content in this area. Currently, there is one template outlining the model for a modified substance diet . However, additional templates may be developed in the future to support various interventions.

  • This template ensures that nutrition diagnosis concepts are modeled in a clear, consistent, and clinically relevant manner, supporting effective documentation and interoperability in healthcare settings.

Two examples are offered as to how the refset could streamline digital nutrition care. Because the Nutrition Refset is relatively new, few implementation examples exist. However, these two scenarios offer insight into possible use cases. First, in Brisbane, Australia, a nutrition diagnosis dashboard using NCPT was developed for internal reports to demonstrate nutrition care outcomes. (This was presented in a May 2024 webinar, which is available with a Commission on Dietetic Registration account https://www.pathlms.com/cdr/courses/69648) And second, Sweden will be transitioning to a new EHR (2024-2025). Dietitians in Sweden see opportunities to incorporate the refset into the transition advancing report generation and demonstrating quality care [personal correspondence]. With the Swedish EHR transition, dietitians are working with nursing to standardize malnutrition diagnostic criteria and nutrition interventions among other issues. The completed nutrition care refset would support this work in Sweden.

Participation in standards development, recognize others with interest in nutrition such as wound care, treatment of dysphagia (https://iddsi.org/events/webinar-promoting-meaningful-electronic-health-information-exchange-between-patient-care-sites-inclusion-of-iddsi-in-snomed-ct) and general nursing practice. Implementation of the refset in these care areas would be expected to grow as interventions are included.

The article accompanying the refset release (Lloyd et al , 2024) suggests additional use cases. The availability of a defined terminology can promote:

1. Cross border demonstration of nutrition care outcomes: US and Australian dietitians comparing Hemoglobin A1C changes after nutrition intervention

2. Cross border and cross-cultural research to assess culturally diverse diets in the treatment of Inflammatory Bowel Disease.

The SNOMED CT Nutrition Care Process Terminology (NCPT) Reference Set is a product agreed as part of a collaboration agreement between the Academy of Nutrition and Dietetics and the International Health Terminology Standards Organisation (IHTSDO), trading as SNOMED International. NCPT content has been incorporated into SNOMED CT and released as a reference set by SNOMED International. This production release is based on NCPT, 2020 edition. Additional concepts in the refset that are not from the NCPT, 2020 edition, are provided as a separate exception list in Appendix D. The current NCPT, 2023 edition, is available at www.nutritioncareprocess.org (log in required). The spreadsheet of NCPT, 2020 edition is available to organizations upon request (www.nutritioncareprocess.org - organization level log in required).

Why is the SNOMED CT NCPT reference set needed?

The SNOMED CT NCPT reference set contains concept references from the SNOMED CT hierarchy, each carefully aligned with the Nutrition Care Process Terminology. In the absence of a dedicated nutrition hierarchy within SNOMED CT, these concepts are sourced from multiple subhierarchies. The reference set effectively organizes these nutrition-specific concepts, streamlining their integration into electronic documentation.

What is it?

When downloaded (for details, see Accessing the NCPT Reference Set), the SNOMED CT NCPT Reference Set is a list of SNOMED CT concept identifiers. To utilize the codes referenced in the set, a user must also have access to the International Edition of SNOMED CT. A user will find in the International Edition of SNOMED CT all the associated concept names and relationships (definitions). Please see below the "Explore the SNOMED CT Reference Set" section and Technical Application.

The initial release of this reference set contained 166 NCPT nutrition problems from the Clinical Finding and Situation with Explicit Context hierarchies. These represent Nutrition Diagnoses from the 2020 Nutrition Care Process Terminology publication including nutrition intake findings, clinical nutrition diagnoses and behavioral-environmental nutrition diagnoses.

The April 2025 release expanded the refset with the addition of nutrition intervention terms mapped to SNOMED CT, bringing the total to 583 concepts across findings, situations, procedures, regime/therapies, and environments. The most recent release (April 2026) contains an additional 1,115 concepts, mostly in the nutrition assessment and monitoring and evaluation domain. Of these, 497 reflect additions or re-mappings introduced in the 2023 NCPT publication. This refset release also includes 1 additional intervention concept and 2 additional diagnostic concepts. Also, the April 2025 refset (intervention and diagnostic concepts) includes additional 2023 NCPT updated content: 139 intervention concepts and 24 diagnostic concepts were added from the 2023 NCPT publication. More information about specific concepts can be found in .

The gradual updating of the SNOMED CT NCPT reference set that prioritized nutrition problems aligns with data from the International NCP Implementation Survey (INIS). INIS is a research consortium of 23 countries across the globe (led by Sweden) tracking the implementation of the NCP and NCPT. Specifically, INIS data showed that countries implement the documentation of nutrition problems first. Further information on the background, motivation and design of the reference set is available in the release notes of the SNOMED CT NCPT Reference Set. See available links below:

Concepts follow the SNOMED naming conventions and the NCPT terms are often included in SNOMED CT as synonyms (when appropriate as preferred terms). NCPT concepts have been modeled in SNOMED CT according to the MRCM (). The Academy of Nutrition and Dietetics maintains an electronic NCPT manual that provides guidance on how to use terms in nutrition and dietetics practice (, subscription log-in required). In the electronic NCPT manual, terms are explained in reference sheets. Reference sheets for nutrition diagnoses provide a definition, common etiologies, and signs and symptoms (defining characteristics). A committee of subject matter experts from around the world has been developing and maintaining the Academy's NCPT since 2003. Terms and definitions have been submitted to SNOMED International as part of the agreement between the two organizations (SNOMED CT and the Academy of Nutrition and Dietetics).

The following pages provide instructions for exploring the members of the NCPT Reference set.

References

Lloyd L, Swan WI, Jent S, Vivanti A, Pertel DG. Worldwide Release of SNOMED CT Nutrition Care Process Terminology Problem List. J Acad Nutr Diet. 2024 Apr;124(4):531-534.

Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, Beck Howarter K, Papoutsakis C. Nutrition Care Process and Model Update: Toward Realizing People-Centered Care and Outcomes Management. J Acad Nutr Diet. 2017 Dec;117:2003-14.

Swan WI, Pertel DG, Hotson B, Lloyd L, Orrevall Y, Trostler N, Vivanti A, Howarter KB, Papoutsakis C. Nutrition Care Process (NCP) Update Part 2: Developing and Using the NCP Terminology to Demonstrate Efficacy of Nutrition Care and Related Outcomes. J Acad Nutr Diet. 2019 May;119:840-55.

Lövestam E, Steiber A, Vivanti A, et al. Use of the Nutrition Care Process and Nutrition Care Process Terminology in an International Cohort Reported by an Online Survey Tool. J Acad Nutr Diet. Feb 2019;119(2):225-241. doi:10.1016/j.jand.2018.09.002

Lövestam E, Vivanti A, Steiber A, et al. Barriers and enablers in the implementation of a standardised process for nutrition care: findings from a multinational survey of dietetic professionals in 10 countries. J Hum Nutr Diet. Jan 7 2020;doi:10.1111/jhn.12700

Lövestam E, Vivanti A, Steiber A, et al. The International Nutrition Care Process and Terminology Implementation Survey: Towards a Global Evaluation Tool to Assess Individual Practitioner Implementation in Multiple Countries and Languages. J Acad Nutr Diet. Feb 2019;119(2):242-260. doi:10.1016/j.jand.2018.09.004

Middeke J, Palmer K, Lövestam E, et al. Predictors of nutrition care process knowledge and use among dietitians internationally. J Hum Nutr Diet. Jun 2022;35(3):466-478. doi:10.1111/jhn.12961

Demonstration Video

The following video shows how to view the members of the NCPT reference set using the SNOMED International SNOMED CT Browser. You can access the browser at browser.snomedtools.org.

Step-by-step Instructions

This step-by-step guide will show you how to view the members of the NCPT reference set using the SNOMED International SNOMED CT Browser.

1. Open the SNOMED CT Browser ()

2. Click "Go browsing...International Derivatives"

3. Click "Refset"

4. Scroll down the list to see the "Nutrition Care Process Terminology reference set" - then click this row

5. Click "Members"

6. Members are shown in the list

Provide Feedback

Nutrition Intervention involves planning and implementing actions to address the nutrition diagnosis.

Several FHIR resources can be used to document these interventions:

• NutritionOrder Resource : Documents detailed nutrition care plans and orders.

• NutritionProduct Resource: Documents foods, fluids and oral nutrition supplements provided to the patient.

The Nutrition Care Process Terminology (NCPT) can be effectively represented using (Health Level 7 Fast Healthcare Interoperability Resources), a standardized framework for healthcare data exchange that ensures consistent and interoperable documentation across various healthcare systems. Notably, standardized documentation of nutrition care using SNOMED CT is a crucial preliminary step, as structured data is more readily exchanged with the HL7 FHIR standard.

The key components of the NCPT; Assessment, Diagnosis, Intervention, and Monitoring and Evaluation map to specific FHIR resources as follows:

• Nutrition Assessment : The Observation, NutritionOrder, NutritionProduct, NutritionIntake, Condition, and ClinicalImpression resources capture dietary habits, anthropometric measurements, and test results, offering a comprehensive view of the patient’s nutritional status.

Nutrition Diagnosis identifies specific nutrition problems that can be addressed through interventions.

Nutrition Diagnosis Data and Associated FHIR Resources

The FHIR Condition resource is primarily used to represent nutrition diagnoses. It captures the nutrition diagnosis using structured data.

• Problem : Represented by the condition code, often using SNOMED CT codes.

• Etiology : Captured in the details or extensions of the Condition resource.

• Signs/Symptoms : Documented as evidence within the Condition resource, referencing relevant Observation resources.

Clinical scenario

This scenario involves a 55-year-old patient with a history of Type 2 diabetes mellitus, managed with medications and lifestyle adjustments. Recent symptoms include unintended weight loss, weakness, and swelling in the lower limbs. Clinical evaluation reveals signs of weight loss and muscle wasting, indicating possible malnutrition exacerbated by chronic diabetes management.

Using FHIR resources, healthcare providers document these findings to support a structured approach to diagnosis and treatment planning.

• The Condition Resource represents the nutrition diagnosis (Malnutrition) using a SNOMED CT code.

  • The evidence section of the Condition resource includes:

    • Etiology : Physiologic–Metabolic; Underlying chronic illness (Type 2 diabetes mellitus) as another Condition

This resource represents the diagnosis of the nutritional disorder (malnutrition).

This resource represents the underlying chronic condition contributing to the nutritional disorder.

Here is a JSON representation of a condition resource detailing a chronic illness, Diabetes mellitus type 2:

This resource uses standard coding systems to describe the clinical and verification statuses, as well as the specific type of diabetes being documented.

This is referenced in the evidence section of the Condition resource, and referencing a condition or observation resource.

This resource documents the presence of unintentional weight loss.

Details:

• Resource Type: Observation

• ID: unintentional-weight-loss

• Status: Final

The following JSON represents an HL7 FHIR Observation for the symptom "Muscle Wasting":

This resource indicates a clinical observation related to the presence of muscle atrophy (disorder) for a patient. The valueBoolean attribute confirms the observation is true.

Linking the Resources

• The Condition Resource for Nutritional Disorder references:

• The Condition Resource for Type 2 Diabetes Mellitus in its evidence.detail array to represent the etiology.

• The Observation Resources for unintentional weight loss and muscle atrophy to represent signs/symptoms.

Introduction

Effective use of the content of the Reference Set requires access to the content in ways that leverage the features of the terminology. A terminology service is a software function that interfaces with and provides access to information from one or more representations of a terminology.

Different technical options are available for implementing terminology services, such as using a relational database, other database options (such as Graph databases ), or predefined services accessible via an API (for example, SNOMED International's Snowstorm).

When deploying the NCPT reference set, it is important to decide on an appropriate approach. The choice will depend on factors such as the organization’s existing infrastructure, the complexity of integration, and the level of flexibility required. Whether opting for a local database solution or a cloud-based service, the decision should ensure efficient retrieval, updates, and management of the terminology content.

Regardless of the technological platform chosen to deploy the Reference Set content, the process always involves importing a SNOMED CT Edition and the reference set in the server or database.

Required Release Packages

To load the NCPT reference set, the RF2 packages required are:

• The latest version of the national release you have access to

  • For national extension packages, the corresponding international edition is also required (the version that the national extension is dependent on)

• The latest version of the NCPT Release Package where the International Edition dependency is not newer than the version you are using.

The NCPT (Nutrition Care Process Terminology) Reference Set is aligned with specific releases of the SNOMED CT International Edition. Each version of the NCPT Reference Set is released annually in April and is dependent on the January release of the International Edition.

For users in a specific country or region, access to the descriptions of the reference set members, including translations, requires the use of the National Edition. The national extension may incorporate localized descriptions for the concepts referenced in the reference set, ensuring translations are available for use in the target language. Without the national extension, users will only have access to the descriptions provided in the International Edition.

National Editions follow independent release cycles, which vary by country or member organization. Some National Editions are released monthly, others quarterly, and some biannually. SNOMED CT is designed to accommodate these variations in release schedules, with comprehensive history tracking to manage any discrepancies that arise due to differing update cycles.

Example Scenario

A National Edition is released in September and is based on the July release of the International Edition.

At the same time, the NCPT Reference Set, dependent on the January International Edition, is required by implementations in this Member country.

In this case, certain concepts within the International Edition that are referenced in the NCPT Reference Set may have been inactivated between the January and July releases.

When the September National Edition is implemented alongside the April version of the NCPT Reference Set, this could result in references to inactive concepts.

To address this, SNOMED CT’s design enables easy identification and resolution of any references to inactive concepts when updating to the new National Edition.

This process ensures that the NCPT Reference Set remains consistent and operational across varying release cycles.

You have two options:

1. Use the Reference set as it is, accepting the risk that some of the components may refer to inactive concepts

• Benefit : No need to spend time and resources on processing or updating the reference set before implementation. This approach allows for quicker deployment, reducing the upfront effort required. Additionally, SNOMED CT provides tools and workarounds, such as historical associations, to mitigate the impact of using inactive content.

• Challenge : Risk of coding with concepts that are inactive in the current version of SNOMED CT

1. Conduct a pre-implementation processing step to resolve any references to inactive concepts

• Benefit : The reference set will be fully aligned with the version of SNOMED CT applied in the implementation

• Challenge : Various requirements needs to be in place, including

  • Expertise knowledge on SNOMED CT

Inactive concepts within the NCPT Reference Set do not present an obstacle for normal use. SNOMED CT provides tools to identify and manage these inactive concepts through Expression Constraint Language (ECL) queries.

To locate references to inactive concepts within the NCPT Reference Set, you can use the following ECL:

This ECL query identifies all concepts within the NCPT Reference Set that are currently inactive (`active = false`). This is useful when you need to review or manage concepts that are no longer active.

If you prefer to work only with active concepts and exclude any that have been inactivated, you can use the inverse ECL:

This query returns only those concepts within the NCPT Reference Set that are currently active (`active = true`). It ensures that you are working with concepts that are up-to-date and valid according to the latest standards.

Additionally, if you need to combine this selection with a hierarchy selection, such as selecting only those concepts within a specific clinical hierarchy, you can do so while ensuring all results are active.

For example, if you are only interested in active concepts within the "Clinical finding" hierarchy, the ECL would be:

This combined ECL query retrieves all active concepts in the NCPT Reference Set that fall within the "Clinical finding" hierarchy, ensuring that your results are both relevant and current.

International Standards and Resources

• International Patient Summary (IPS)

  • Essential medical information for unplanned, cross border medical care. Allergies and intolerances, medications, medical devices (feeding pumps, central lines). To be implemented in 2025. Refugees with food insecurity or malnutrition(undernutrition).

• European Patient Summary

  • Essential medical information for unplanned medical care within the EU. Internally displaced persons with food insecurity or malnutrition (undernutrition).

• pan-Canadian Patient Summary Specification (PS-CA)

  • Essential medical information for unplanned medical care within Canada.

• Korean CDA Implementation Guide (K-CDA IG)

  • Adapted HL7 CDA standards to meet needs of the local healthcare system.

  • Jung S, Bae S, Seong D, Yi B. Standard Document Development for Health Information Exchange in Korea. Appl Clin Info 13:3, 592-601, 2022.

• HL7

  • FHIR, relationship described in Section 5

  • HL7 Domain Analysis Model for Nutrition Care Release 3, Universal Realm

• Consolidated Clinical Documentation Architecture (C-CDA)

  • HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Nutrition, US Realm

• Value Set Authority Center (VSAC), National Institutes of Health, National Library of Medicine

The translation of reference set members involves creating meaningful and linguistically appropriate descriptions for the concepts referenced by the subset. These descriptions are added within the national extension of SNOMED CT, ensuring that healthcare professionals can understand and use the terminology effectively in their local language and clinical context.

Creating Descriptions for Referenced Concepts

The reference set itself does not contain descriptions but instead includes references to specific SNOMED CT concepts.

Translating reference set members involve:

1. Adding Descriptions for Referenced Concepts:

   • For each concept in the reference set, create one or more descriptions for the concept in the target language.

   • These descriptions ensure that the clinical intent of each concept is clear and usable by healthcare professionals in the target region.

2. Maintaining Semantic Integrity:

   • Ensure that the translated descriptions accurately reflect the original meaning of the concepts while using natural language familiar to the target audience.

3. Integration into the National Extension:

   • The translated descriptions are added to the national extension of SNOMED CT, which incorporates the localized content while maintaining alignment with the International Edition.

The translation process should be conducted in collaboration with the National Release Center (NRC) to:

• Ensure Consistency Across Extensions: Work with the NRC to maintain consistent translations across the national extension, avoiding discrepancies between reference sets and other SNOMED CT components.

• Leverage Expertise: Utilize the NRC’s access to clinical, linguistic, and terminological experts to validate the quality and usability of the translations.

• Support Updates: Coordinate with the NRC to integrate translated descriptions into the national extension and manage updates as SNOMED CT evolves.

• Enhanced Usability: Descriptions in the local language make the reference set more accessible to healthcare professionals.

• Improved Data Quality: Localized descriptions reduce the risk of misinterpretation and improve the accuracy of clinical documentation.

• Alignment with National Standards: Ensures the reference set reflects local healthcare practices and terminologies.

• Sweden, contains diagnostic terms, release November 2024

More information

Overview of Members and contact details:

Translation Guidance and principles:

General SNOMED CT Glossary

Nutrition Monitoring and Evaluation involve tracking the patient's progress and the outcomes of nutrition interventions.

Nutrition Monitoring and Evaluation

Nutrition Monitoring and Evaluation involve tracking the patient's progress and the outcomes of nutrition interventions.

Nutrition Monitoring and Evaluation Data and Associated FHIR Resources

FHIR resources used for this purpose include:

• Observation Resource : Continues to be crucial for ongoing measurements and assessments.

• NutritionIntake Resource : Details about the consumption of foods (i.e., solid and/or liquid), supplements, enteral nutrition, and infant formula.

• NutritionProduct Resource: Identification of a food (i.e., solid and/or liquid) product provided to patients.

• Goal Resource : Tracks specific nutrition-related goals and their outcomes.

• Condition Resource : Updated to reflect changes in the patient’s condition as a result of interventions.

• CarePlan Resource : Monitors and evaluates the overall care plan, adjusting interventions as needed.

Purpose

This appendix documents all SNOMED CT concept additions, remaps, semantic tag updates, international extension substitutions, and omissions that differ from the 2020 NCPT baseline release.

The appendix reflects changes introduced in:

• April 2025 NCPT Refset release

• April 2026 NCPT Refset release

The purpose is to support:

• implementation migration from legacy 2020 NCPT mappings

• terminology governance review

• analytics and reporting refset maintenance

• EHR build validation

The following summarizes the delta from the 2020 NCPT baseline.