Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition.
Description (*Please confirm or update this field for the new USCDI version*)
Assessment of a person’s dietary intake.
Submitted By: Michelle Ashafa
/ Academy of Nutrition and Dietetics
Data Element Information
Data Element Description
A systematic nutrition assessment of an individual's nutrition intake, physical exam, anthropometric measurements, biochemical, and health condition data compared to accepted standards, recommendations, and/or goals to arrive at a determination of the client’s nutrition well-being or malnutrition.
Use Case Description(s)
Use Case Description
Among the initial assessments in healthcare settings, a comprehensive nutritional evaluation is performed to establish a baseline Nutrition Status. This involves nutrition intake patterns and food availability, clinical evaluations like anthropometric measurements (BMI, waist circumference, etc.), and laboratory tests like mineral status, vitamin levels, or other nutrient markers and encompasses various medical professionals in its completion. Upon admitting a patient with a chronic condition, such as diabetes, kidney disease, heart disease, or before surgery, understanding the patient's Nutrition Status is essential to the plan of care. It aids in personalizing meal plans during a hospital stay to optimize a return to health. It helps in predicting recovery rates and potential complications. It assists in tailoring food and nutrition transitions of care. When a primary care provider refers a patient to a specialist, such as an endocrinologist for diabetes management or a registered dietitian for specific nutritional therapy, the Nutrition Status should be available to provide care providers with a comprehensive understanding of the patient's nutritional baseline.
Frequency of use would be every time a patient is admitted or re-admitted to the hospital or care setting, when a referral is generated, or when a change in health status occurs.
Estimate the breadth of applicability of the use case(s) for this data element
Level 2 - Use cases apply to most care settings or specialties.
To manage conditions, such as cancer, the NCP contributes to the development, modification, and communication of the Nutrition Status to the care team.
Nutrition Assessment provides a baseline on the nutritional contributors to the patient's nutrition status and problem(s) and enables targeted and effective interventions. Effective interventions consider the comprehensive nutrition status of the patient, social determinants that may impact care, and the medical treatment plan (eg, surgery, chemotherapy) improving the ability to adhere to medical therapies and better treatment outcomes. Nutrition Monitoring and Evaluation, the continuous review of the nutritional status, ensures that the interventions are and remain effective and can be modified as the patient's needs change. The nutrition status helps inform the standardized evidence-based approach to nutritional management.
Estimate the breadth of applicability of the use case(s) for this data element
Nutrition Status is universally applicable across all age groups. From pediatric care (evaluating growth, development, and nutritional adequacy) to geriatric care (where malnutrition risk is heightened), every age bracket can benefit. On a broader scale, understanding the nutritional status of populations can guide public health initiatives, policies, and interventions.
ONC Priority
Address behavioral health integration with primary care and other physical care
Mitigate health and health care inequities and disparities
Address the needs of underserved communities
Maturity of Use and Technical Specifications for Data Element
HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Nutrition, Release 1 - US Realm.
4.2 Diagnosis Etiology (Nutrition)
a. This code SHALL contain exactly one [1..1] @code="75306-1" Nutrition Status Etiology (CONF:3352-165).
5. SHALL contain exactly one [1..1] code (CONF:3352-147).
Nutrition Diagnosis (Nutrition)
5. SHALL contain exactly one [1..1] code (CONF:3352-555). a. This code SHALL contain exactly one [1..1] @code="75305-3" Nutrition Status (CONF:3352-556).
Current Use
(Level 0) Captured, stored, or accessed in limited settings such as a pilot or proof of concept demonstration
Extent of exchange
(Level 0) Limited environments, such as connectathons or pilots
Supporting Artifacts
EHRs commonly incorporate nutrition assessment tools for patients to detail their food habits, allergies, and supplement intake. These systems also capture essential metrics such as BMI, weight changes, and specific lab results like vitamin D levels. To ensure consistency and ease of access, EHRs have designated fields for such metrics, along with special sections for dietitians to input thorough nutritional assessments. Additionally, some health institutions integrate nutrition status assessment tools within their main EHR to centralize patient data.
Such examples are C-CDA R2.1 Supplemental Templates for Nutrition.
Organizations may use HL7 V2 standards and C-CDA R2.1 Supplemental Templates for Nutrition to exchange Nutrition status related data elements. The emerging development and use of the FHIR Resources: NutritionOrder. NutritionProduct, and NutritionIntake expand the applicability of Nutrition Status data element for electronic exchange. NutritionOrder resource is at a maturity level of FMM 3. Nutrition Product and NutritionIntake stand at a maturity level of FMM 2.
Restrictions on Standardization (e.g. proprietary code)
Standardization of nutrition status through LOINC 75304-6 Nutrition status observation panel promotes interoperable exchange of nutrition findings.
Restrictions on Use (e.g. licensing, user fees)
There are no restrictions on the use of nutrition status or nutrition status data elements.
Privacy and Security Concerns
The concepts within this proposed data element are currently being exchanged and will continue to follow privacy and security requirements if applicable.
Estimate of Overall Burden
Nutrition status data in EHRs are data that are readily available, like food allergies, anthropometric, and lab data results. While some results, such as vitamin D levels, may come from external lab systems, many EHRs already have these integrated, easing the burden on implementers. Some nutrition data such as food and nutrition patterns require manual input. All of the data is part of standard workflows, with the primary challenge being the efficient and meaningful consolidation and reporting of this data by implementers.
ASTP Evaluation Details Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1 Maturity - Current Standards
Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2 Maturity - Current Use
Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3 Maturity - Current Exchange
Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4 Use Case(s) - Breadth of Applicability
Level 2 - Use cases apply to most care settings or specialties.
Recommendation: Advance the Nutrition Status data element from Level 0 to Level 2.
Rationale: The PACIO Project Community*, including the Academy of Nutrition and Dietetics, recommends advancing the Nutrition Status data element from Level 0 to Level 2 in accordance with the USCDI Data Element Leveling Criteria. The PACIO Project’s clinical community of practice agrees with the Academy of Nutrition and Dietetics that these comprehensive nutrition assessments are critical to patient safety, health, and recovery. The PACIO team has identified evidence that this data element meets Level 2 criteria, as described below.
The nutrition status data generated through comprehensive nutrition assessments support healthcare practitioners, who consider food, eating, and nutrition in their clinical decision-making and therefore need access to nutrition specialists’ insights into patients’ dietary needs. Dietitians provide needed information about malnutrition risk, dietary intake, and other specialist information that impact patient safety and care decisions across settings and care-team members. Ultimately, nutrition status is important for patient outcomes and safety in care settings and at home, including during transitions of care, making the Nutrition Status data element critical for capture within and transmission between EHR systems.
Clinical Relevance: While the new Nutrition Order data element captures prescribed diets, the Nutrition Status data element reflects the patient’s underlying nutritional health including malnutrition risk, swallowing safety, self-feeding ability, and nutrient intake. It serves as the clinical driver for Nutrition Orders and referrals to registered dietitian nutritionists (RDNs), speech-language pathologists (SLPs), occupational therapists (OTs), and nursing teams. Documenting Nutrition Status in the EHR at admission ensures timely follow-up, supports safe care planning, and aligns with the CMS Malnutrition Care Score (MCS), which requires nutrition screening, assessment, diagnosis, and care planning.1 Regulatory standards mandate that hospitals conduct a nutrition screening for all applicable patients within 24 hours of their inpatient admission with the results documented in the patient's Electronic Health Record (EHR)2.
USCDI Level Criteria:
Current Standards:Level 2 – Nutrition Status is represented by several terminology standards.
The SNOMED CT Nutrition Reference Set includes standardized concepts for nutritional findings, malnutrition risk, and feeding ability, ensuring consistency across providers and enabling integration into care planning and outcome tracking.
LOINC includes key codes such as 75305-3 (Nutrition status).
The CMS Data Element Library (DEL) requires documentation of nutrition status related information, such as swallowing, through the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI)3, Section K (Swallowing/Nutritional Status) for all certified nursing facilities.
Current Use: Level 2 – Nutrition status is captured in multiple production EHRs or other HIT modules from more than one developer as many care facilities are required to document nutrition status.
In long-term care, the MDS Section K data are federally-mandated and reported to CMS by care facilities.
In hospitals, based on regulations, when applicable, nutrition screening is required by the Joint Commission to be completed and documented within 24 hours of admission, using validated tools such as the Malnutrition Screening Tool (MST) to document nutrition status in EHRs.
Current Exchange: Level 2 – There are multiple HIT modules using Nutrition Status.
Hospitals are required to document and transmit nutrition information, such as malnutrition screening results, to skilled nursing facilities that are required to document nutrition status across multiple CMS required post acute assessments. Therefore, current HIT systems have the capability to transmit nutrition status information.
HL7 FHIR pilots are demonstrating interoperable exchange of nutrition data using the Observation resource (for anthropometrics and nutrition-focused findings) and the Condition resource (for malnutrition and related diagnoses).
Breadth of Applicability: Level 2 – Use cases for Nutrition Status apply to most care settings as demonstrated by guidelines and requirements for documenting this data element in acute and post-acute settings.
Acute care settings are encouraged to follow guidelines from professional organizations, such as the American Society for Parenteral and Enteral Nutrition (ASPEN) which has developed nutritional support guidelines for hospital patients. These guidelines include Standard 5.2, which states “The nutrition assessment shall include evaluation of the patient's current nutrition status and nutrition requirements.”
Post acute care settings, as described earlier, must capture nutrition status as required by CMS.
* The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, that aims to advance interoperable health information exchange between post-acute care (PAC) providers, patients, and other key stakeholders across health care.
Recommendation: Advance the Nutrition Status data element from Level 0 to Level 2.
Rationale: The PACIO Project Community* recommends advancing the Nutrition Status data element from Level 0 to Level 2. This information is often collected by a nutrition specialist, such as a registered dietitian (RD), and includes comprehensive nutritional assessments that account for allergies, swallowing ability, and nutrient needs, among other things. The PACIO Project’s clinical community of practice agrees with the Academy of Nutrition and Dietetics that these comprehensive nutrition assessments are critical to patient safety, health, and recovery. These comprehensive nutrition assessments support the clinical decision-making of healthcare practitioners, such as physicians, advanced practice nurses, speech language pathologists, occupational and physical therapists, and pharmacists, who consider food, eating, and nutrition in their clinical decision-making and therefore need access to nutrition specialists’ insights into patients’ dietary needs. Dietitians provide needed information about malnutrition risk, dietary intake, and other specialist information that impact patient safety and care decisions across settings and care-team members. Ultimately, nutrition status is important for patient outcomes and safety in care setting and at home, including during transitions of care, making the Nutrition Status data element critical for capture within and transmission between EHR systems.
* The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange.
Recommendation: Advance the Nutrition Status data element from Level 0 to Level 2.
Rationale: The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange.
The PACIO Project’s clinical community of practice agrees with the Academy of Nutrition and Dietetics that comprehensive nutrition assessments are critical to patient safety, health, and recovery. Comprehensive nutrition assessments allow all practitioners who must consider food, eating, and nutrition, to have specialist insight into a patient’s dietary needs. These providers include practitioners, speech language pathologists, occupational and physical therapists, and pharmacists. Dietitians provide needed information about malnutrition risk, dietary intake, and other specialist information that impact patient safety and care decisions across settings and care-team members.
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Submitted by jpatterson@mitre.org on
PACIO Recommends Advancing Nutrition Status to Level 2