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.
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.
Value Set Authority Center (VSAC), NLM
Nutrition Focused Physical Findings Grouping
Academy of Nutrition and Dietetics
372
Condition.code
Members of the Nutrition Care Process Terminology reference set
^ 1303957004
Nutrition Care Process Terminology reference set
Condition.evidence.code
N/A
< 404684003
Clinical finding
Value Set Authority Center (VSAC), NLM
Nutrition Diagnosis Grouping
Academy of Nutrition and Dietetics
167
Nutrition Intervention: The NutritionOrder , NutritionProduct , Procedure , and CarePlan resources document detailed nutrition care plans, specific interventions, and strategies for managing nutrition-related issues.
Nutrition Monitoring and Evaluation: The Observation , Goal , Condition , and CarePlan resources are used to track ongoing measurements, monitor progress toward goals, update condition statuses, and review and adjust care plans as needed.
In the context of HL7 FHIR and SNOMED CT, terminology binding defines how clinical data elements are represented within FHIR resources. Each data element in a FHIR resource is linked to a specific value set, which dictates the permissible SNOMED CT codes or concepts for that element.
For example, when recording a patient’s condition in a FHIR resource, the “code” field is bound to a specific SNOMED CT code that accurately represents the condition. This standardized approach ensures that healthcare providers and systems use consistent terminology to describe clinical information across different platforms and contexts.
By adhering to these value sets, FHIR enables precise data exchange and a shared understanding of clinical data elements, enhancing interoperability, supporting efficient healthcare delivery, and contributing to improved patient outcomes.
The following pages will provide detailed recommendations for terminology bindings between relevant FHIR resources and SNOMED CT value sets, specifically as they apply to representing the Nutrition Care Process Terminology (NCPT). Each section will outline the application of specific FHIR resources and bindings to support different NCPT components.
HL7 FHIR is a modern standard designed to facilitate the exchange of healthcare information electronically. The standard defines resources, i.e. data formats, that can be used to represent data elements in a systematic way across the healthcare continuum.
Consistency : With standardized resources and robust semantics, FHIR ensures uniformity in healthcare data representation. This consistency supports accurate data exchange and enables healthcare providers to make informed decisions based on reliable information, ultimately enhancing patient care quality.
Modularity : FHIR’s flexible architecture allows its resources to be used independently or in combination to meet specific healthcare needs. This modular approach supports adaptability across diverse healthcare contexts, enabling tailored solutions without overhauling entire systems.
Interoperability : FHIR facilitates seamless data exchange between different healthcare systems and applications, enhancing communication and collaboration among healthcare providers. By standardizing data formats and protocols such as RESTful APIs and JSON/XML, FHIR promotes interoperability, improving patient care coordination and information sharing.
Standardization : FHIR leverages contemporary web standards to ensure compatibility with existing IT infrastructures. By defining well-structured resources like Patient, Observation, and Medication with clear semantics, FHIR fosters consistency in how healthcare data is represented and interpreted across various systems.
Scalability : Designed to accommodate evolving healthcare requirements and technological advancements, FHIR is scalable for both current and future healthcare needs. Its flexible architecture and support for extensibility allow healthcare systems to grow and adapt without compromising interoperability or data integrity.
HL7 FHIR plays a crucial role in linking healthcare data with standard terminologies, including SNOMED CT. By integrating FHIR with terminologies like SNOMED CT, a more precise and standardized documentation and communication of clinical information can be achieved. This linkage enhances interoperability by enabling seamless exchange of structured clinical data, supporting accurate clinical decision-making, and promoting continuity of care for patients across various healthcare settings.
Together, FHIR and SNOMED CT facilitate a unified approach to healthcare information management, benefiting both vendors, healthcare providers and patients.
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.
Procedure Resource : Records specific nutrition-related procedures and interventions.
CarePlan Resource : Provides a comprehensive plan of care that includes nutrition interventions.
This example demonstrates how the NutritionOrder resource can be used to document and manage dietary requirements, restrictions, and preferences for a patient. It illustrates a comprehensive cardiac diet order for an inpatient, including specific instructions, nutrient modifications, and food exclusions.
Key features highlighted in this example:
Diet Type: Includes a low sodium diet and fluid-restricted diet to address cardiac health needs.
Nutrient Specifications: Details on limiting sodium intake to 2 grams per day and fluids to 1500 milliliters per day.
Allergies and Exclusions: Accounts for patient-specific allergies (e.g., cashew nuts) and excludes related food items.
Personalization:
This example is based on the official and showcases how NutritionOrder supports structured, interoperable dietary management in healthcare.
For more examples and detailed use cases, refer to the and .
Nutrition Monitoring and Evaluation involve tracking the patient's progress and the outcomes of nutrition interventions.
Nutrition Monitoring and Evaluation involve tracking the patient's progress and the outcomes of nutrition interventions.
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.
Nutrition Diagnosis identifies specific nutrition problems that can be addressed through interventions.
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.
Provides regular updates on the patient’s status
Weekly progress report on dietary changes
Observation
Outcome Tracking
Monitors progress towards achieving specific nutrition-related goals
Goal: Reduce BMI to 22 within 3 months
Goal
Status Updates
Documents changes in the status of the nutrition diagnosis
Condition improved from malnutrition to stable
Condition
Plan Review and Adjustment
Reviews the care plan, documenting changes and updates
Adjusted diet plan due to weight gain
CarePlan
Monitoring Parameters
Tracks ongoing measurements like weight, BMI, lab values, dietary intake
Weight: 70 kg, BMI: 25, Daily calorie intake
ObservationNutritionIntakeNutritionProduct
Progress Notes
Specify schedules for meals, oral supplements (e.g., protein shakes), or other forms of nutrition support.
TPN daily at night, Supplements twice daily
NutritionOrder
Nutrition Counseling
Capture details of counseling sessions and educational interventions to improve nutrition knowledge or behavior.
Nutrition education session on diabetic diet
Procedure
Feeding Tube Placement
Record details of procedures related to the placement of feeding tubes for enteral nutrition support.
Placement of nasogastric feeding tube
Procedure
Goals and Objectives
Outline specific, measurable nutrition-related goals that guide the overall care plan.
Increase weight by 2 kg in 1 month
CarePlan
Activities and Interventions
Coordinate actions such as administering supplements, monitoring tube feeding, or adjusting dietary plans as needed.
Administer supplements, Monitor tube feeding
CarePlan
Instructions: Provides specific guidance on meal preparation and fluid allowances.
Food and Nutrient Delivery
Document specific details of diets, oral supplements, or enteral/parenteral nutrition plans, including prescribed nutrition interventions.
High-protein diet, Tube feeding with formula
NutritionOrder, NutritionProduct
Timing and Frequency
{
"resourceType" : "NutritionOrder",
"id" : "cardiacdiet",
"identifier" : [{
"system" : "http://goodhealthhospital.org/nutrition-requests",
"value" : "123"
}],
"status" : "active",
"intent" : "order",
"subject" : {
"reference" : "Patient/example",
"display" : "Peter Chalmers"
},
"encounter" : {
"reference" : "Encounter/example",
"display" : "Inpatient"
},
"dateTime" : "2014-09-17",
"orderer" : {
"reference" : "Practitioner/example",
"display" : "Dr Adam Careful"
},
"allergyIntolerance" : [{
"reference" : "AllergyIntolerance/example",
"display" : "Cashew Nuts"
}],
"foodPreferenceModifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/diet",
"code" : "dairy-free"
}]
}],
"excludeFoodModifier" : [{
"coding" : [{
"system" : "http://snomed.info/sct",
"code" : "227493005",
"display" : "Cashew Nut"
}]
}],
"oralDiet" : {
"type" : [{
"coding" : [{
"system" : "http://snomed.info/sct",
"code" : "386619000",
"display" : "Low sodium diet"
},
{
"system" : "http://goodhealthhospital.org/diet-type-codes",
"code" : "1040",
"display" : "Low Sodium Diet"
}],
"text" : "Low sodium diet"
},
{
"coding" : [{
"system" : "http://snomed.info/sct",
"code" : "226208002",
"display" : "Fluid restricted diet"
},
{
"system" : "http://goodhealthhospital.org/diet-type-codes",
"code" : "1040",
"display" : "Fluid restricted diet"
}],
"text" : "Fluid restricted diet"
}],
"nutrient" : [{
"modifier" : {
"coding" : [{
"system" : "http://snomed.info/sct",
"code" : "39972003",
"display" : "Sodium"
}]
},
"amount" : {
"value" : 2,
"unit" : "grams",
"system" : "http://unitsofmeasure.org",
"code" : "g"
}
},
{
"modifier" : {
"coding" : [{
"system" : "http://snomed.info/sct",
"code" : "33463005",
"display" : "Fluid"
}]
},
"amount" : {
"value" : 1500,
"unit" : "milliliter",
"system" : "http://unitsofmeasure.org",
"code" : "mL"
}
}],
"instruction" : "Starting on 2/10 breakfast, maximum 400 ml fluids per meal"
}
}Signs/Symptoms : Documented as evidence within the Condition resource, referencing relevant Observation resources.
Diagnosis
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 resource.
Signs/Symptoms : Unintended weight loss and Muscle wasting, which are represented as Observation resources linked to the condition. These observations document the presence of each symptom (Boolean value true).
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
Category: Clinical
Code: 448765001 - Unintentional weight loss (finding)
Subject Reference: Patient/example
Symptom Presence: True
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.
All resources reference the same patient (Patient/example) for proper linkage and context.
{
"resourceType": "Condition",
"id": "nutritional-disorder",
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code": "active",
"display": "Active"
}
]
},
"verificationStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
"code": "confirmed",
"display": "Confirmed"
}
]
},
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "2492009",
"display": "Nutritional disorder (disorder)"
}
]
},
"subject": {
"reference": "Patient/example"
},
"evidence": [
{
"detail": [
{
"reference": "Condition/diabetes"
},
{
"reference": "Observation/weight-loss"
},
{
"reference": "Observation/muscle-atrophy"
}
]
}
]
}{
"resourceType": "Condition",
"id": "diabetes",
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
"code": "active",
"display": "Active"
}
]
},
"verificationStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
"code": "confirmed",
"display": "Confirmed"
}
]
},
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "44054006",
"display": "Diabetes mellitus type 2 (disorder)"
}
]
},
"subject": {
"reference": "Patient/example"
}
}{
"resourceType": "Observation",
"id": "unintentional-weight-loss",
"status": "final",
"category": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
"code": "clinical",
"display": "Clinical"
}
]
}
],
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "448765001",
"display": "Unintentional weight loss (finding)"
}
]
},
"subject": {
"reference": "Patient/example"
},
"valueBoolean": true
}{
"resourceType": "Observation",
"id": "muscle-atrophy",
"status": "final",
"category": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
"code": "clinical",
"display": "Clinical"
}
]
}
],
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "88092000",
"display": "Muscle atrophy (disorder)"
}
]
},
"subject": {
"reference": "Patient/example"
},
"valueBoolean": true
}Problem
Represents the primary nutrition-related problem using a condition code
Malnutrition
Condition
Etiology
Details the cause or contributing factors for the diagnosis
Physical Function, Social-personal
Condition
Signs/symptoms
Documents observable signs or symptoms that support the diagnosis
Documented as evidence within the Condition resource, referencing relevant Observation resources.
Unintended weight loss, muscle wasting
Observation
Condition
Food- and nutrition-related history
Capture dietary habits and intake information
Food diary entries
Observation NutritionOrderNutritionProduct****NutritionIntake
Anthropometric measurements
Record physical measurements such as weight, height, BMI
Weight: 70 kg, Height: 170 cm
Observation
Tests
Document laboratory or diagnostic tests
Blood glucose levels
Observation
Test results
Record results of tests
Hemoglobin A1c: 5.5%
Observation
Nutrition-focused physical examination findings
Detailed findings from a nutrition-focused physical exam
Skin condition, hair texture
Observation****Condition
Patient history
Capture medical history
Chronic conditions, surgeries
Observation
Nutrition Assessment
[code]
{
"resourceType": "Observation",
"id": "observation-weight",
"status": "final",
"category": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
"code": "vital-signs",
"display": "Vital Signs"
}
]
}
],
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "27113001",
"display": "Body weight (observable entity)"
}
],
"text": "Body Weight"
},
"subject": {
"reference": "Patient/example"
},
"valueQuantity": {
"value": 70,
"unit": "kg",
"system": "http://unitsofmeasure.org",
"code": "kg"
}
}
[/code]