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12.19 Resource NutritionOrder - Content

Orders and Observations icon Work GroupMaturity Level: 3 Trial UseSecurity Category: Patient Compartments: Encounter, Group, Patient, Practitioner

A request to supply a diet, formula feeding (enteral) or oral nutritional supplement to an individual or group.

12.19.1 Scope and Usage

Note to Implementers: For an overview of this resource and others in the Nutrition domain, also see the module page.

This resource is a request resource from a FHIR workflow perspective - see Workflow. It is the intent of the Orders and Observation Workgroup to align this resource with the workflow pattern for request resources.

The NutritionOrder resource describes a request for oral diets (including general diets such as General Healthy diet, or therapeutic diets such as Consistent Carbohydrate, 2-gram Sodium, or Fluid Restricted), oral nutrition supplements (such as nutritionally complete pre-packed drinks), enteral nutrition (tube feedings) and infant formula which govern the distribution of food and nutritional products used to feed patients within a patient setting. It does not cover orders for parenteral (IV) nutrition which are typically filled by pharmacy. These nutrition orders are combined with information on a patient's food allergies and intolerances, and ethnic or cultural food preferences (e.g. Kosher or Vegetarian) to inform healthcare personnel about the type, texture, and/or quantity of foods that the patient should receive or consume.

Enteral orders are distinguished from supplements because they have some unique attributes and typically include administration information whereas oral nutritional supplements may simply be supplied (e.g. home health or outpatient settings). In a simple case, the requestor may designate the type of product, product name, and the route of administration along with free text instructions without having to complete the additional structured details.

This resource is intended to be used by practitioners from a variety of specialties such as physicians, dietitians/nutritionists, or speech therapists. One practitioner may simply order a base element oral diet such as General Healthful diet. Another practitioner, based on the scope of practice, may use other elements to communicate additional therapeutic needs or patient preferences. The optionality included gives an ordering practitioner the capability to write a simple order for an oral diet, nutritional supplement or formula with minimal requirements beyond that of specifying the diet, supplement or formula product, but also supports the ability to provide more detailed information that may be further augmented by a dietitian or nutrition specialist. For example, a physician may order a 2 g sodium diet. A speech therapist, based on the results of a swallowing evaluation, then orders an International Dysphagia Diet Standardisation Initiative Framework - Soft and Bite-Sized Level 6 food (regime/therapy).

12.19.2 Boundaries and Relationships

The NutritionOrder resource is used for requesting oral diets, oral nutrition supplements, enteral feedings, and infant formula. The MedicationRequest resource should be used for requesting parenteral (IV) nutrition and prescribing dietary supplements such as vitamin or mineral supplements.

The Nutrition Order is a record of the request for the supply of a diet, oral supplement, enteral formulas, and infant formula for a patient. However, to initiate the request requires the use of the Task resource and its associated workflow with the Nutrition Order referenced from Task.basedOn, or by using the nutrition Task resource in the context of a messaging or service workflow where the request is explicit or implicit. For further information about this separation of responsibilities, refer to the Fulfillment/Execution section of the Request pattern.

12.19.3 References to this Resource

12.19.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. NutritionOrder TU DomainResource Diet, formula or nutritional supplement request
+ Rule: Nutrition Order SHALL contain either Oral Diet , Supplement, or Enteral Formula class

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..* Identifier Identifiers assigned to this order

... instantiatesCanonical Σ 0..* canonical(ActivityDefinition | PlanDefinition) Instantiates FHIR protocol or definition

... basedOn 0..* Reference(CarePlan | NutritionOrder | ServiceRequest | RequestOrchestration) What this order fulfills

... status ?!Σ 1..1 code draft | active | on-hold | entered-in-error | ended | completed | revoked | unknown
Binding: RequestStatus (Required)
... intent ?!Σ 1..1 code proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option
Binding: RequestIntent (Required)
... priority 0..1 code routine | urgent | asap | stat
Binding: RequestPriority (Required)
... subject Σ 1..1 Reference(Patient | Group) Who requires the diet, formula or nutritional supplement
... encounter 0..1 Reference(Encounter) The encounter associated with this nutrition order
... supportingInformation 0..* Reference(Any) Information to support fulfilling of the nutrition order

... dateTime Σ 1..1 dateTime Date and time the nutrition order was requested
... requester Σ 0..1 Reference(Practitioner | PractitionerRole) Who ordered the diet, formula or nutritional supplement
... performer 0..* CodeableReference(CareTeam | Practitioner | PractitionerRole | RelatedPerson | Patient | Organization | Group) Who is intended to perform the administration of the nutrition order

... allergyIntolerance 0..* Reference(AllergyIntolerance) List of the patient's food and nutrition-related allergies and intolerances

... foodPreferenceModifier 0..* CodeableConcept Order-specific modifier about the type of food that should be given
Binding: Types of Edible Substances (Preferred)

... excludeFoodModifier 0..* CodeableConcept Food that should not be given
Binding: Types of Edible Substances (Preferred)

... outsideFoodAllowed 0..1 boolean Capture if patient is permitted to consume food from outside of current setting brought by the patient, family, and/or caregiver
... oralDiet C 0..1 BackboneElement Oral diet components
.... type Σ 0..* CodeableConcept Type of oral diet or diet restrictions that can be consumed orally
Binding: Diet Codes (Preferred)

.... schedule 0..1 BackboneElement Scheduling information for oral diets
..... timing 0..* Timing Scheduled frequency of diet

..... asNeeded 0..1 boolean Take 'as needed'
..... asNeededFor 0..1 CodeableConcept Take 'as needed' for x
Binding: SNOMED CT Medication As Needed Reason Codes (Example)
.... nutrient 0..* BackboneElement The nutrient that is modified and the quantity in the diet

..... modifier 0..1 CodeableConcept Nutrient modified in the oral diet type
Binding: Nutrient Codes (Preferred)
..... amount 0..1 Quantity Quantity of the specified nutrient
.... texture 0..* BackboneElement Texture modifications in addition to the oral diet type

..... modifier 0..1 CodeableConcept Food (i.e. solid and/or liquid) texture modifications in addition to those in the oral diet type
Binding: Categories of Nutrition Products (Preferred)
..... type 0..1 CodeableConcept Food (i.e. solid and/or liquid) types that undergo texture alteration
Binding: Texture Modified Food Type Codes (Example)
.... instruction Σ 0..1 string Instructions or additional information about the oral diet
.... caloricDensity 0..1 Quantity Amount of energy per specified volume of oral diet
... supplement C 0..* BackboneElement Supplement components

.... type Σ 0..1 CodeableReference(NutritionProduct) Type of supplement product requested
Binding: Supplement Type Codes (Preferred)
.... productName 0..1 string Product or brand name of the nutritional supplement
.... schedule 0..1 BackboneElement Scheduling information for supplements
..... timing 0..* Timing Scheduled frequency of supplement

..... asNeeded 0..1 boolean Take 'as needed'
..... asNeededFor 0..1 CodeableConcept Take 'as needed' for x
Binding: SNOMED CT Medication As Needed Reason Codes (Example)
.... quantity 0..1 Quantity Amount of the nutritional supplement
.... instruction Σ 0..1 string Instructions or additional information about the oral supplement
.... caloricDensity 0..1 Quantity Amount of energy per specified volume of supplement that is required
... enteralFormula C 0..1 BackboneElement Enteral formula product
.... type Σ 0..1 CodeableReference(NutritionProduct) Type of patient enteral feeding
Binding: Enteral Formula Type Codes (Preferred)
.... productName 0..1 string Product or brand name of the enteral feeding
.... deliveryDevice 0..* CodeableReference(DeviceDefinition) Intended type of device for the enteral feeding administration

.... caloricDensity 0..1 Quantity Amount of energy per specified volume of feeding that is required
.... routeOfAdministration 0..* CodeableConcept How the enteral feeding should enter the patient's gastrointestinal tract
Binding: Enteral Route Codes (Extensible)

.... administration 0..* BackboneElement Formula feeding instruction as structured data

..... schedule 0..1 BackboneElement Scheduling information for enteral feeding products
...... timing 0..* Timing Scheduled frequency of enteral feeding

...... asNeeded 0..1 boolean Take 'as needed'
...... asNeededFor 0..1 CodeableConcept Take 'as needed' for x
Binding: SNOMED CT Medication As Needed Reason Codes (Example)
..... quantity 0..1 Quantity The volume of formula feeding to provide
..... rate[x] 0..1 Speed with which the formula feeding is provided per period of time
...... rateQuantity Quantity
...... rateRatio Ratio
.... maxVolumeToAdminister 0..1 Quantity Upper limit on formula feeding volume per unit of time
.... administrationInstruction Σ 0..1 markdown Formula feeding instructions expressed as text
... additive 0..* BackboneElement Modular additive to add to the oral diet, supplement, and/or enteral feeding

.... modularType 0..1 CodeableReference(NutritionProduct) Type of modular component to add to the oral diet, supplement, and/or enteral feeding
Binding: Enteral Formula Additive Type Code (Preferred)
.... productName 0..1 string Product or brand name of the modular additive
.... quantity 0..1 Quantity Amount of additive to be given or mixed in with the oral diet, supplement, and/or enteral feeding
.... routeOfAdministration 0..* CodeableConcept How the additive should enter the patient's gastrointestinal tract
Binding: Enteral Route Codes (Extensible)

... note 0..* Annotation Comments


doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

12.19.4.1 Terminology Bindings

Path ValueSet Type Documentation
NutritionOrder.status RequestStatus Required

Codes identifying the lifecycle stage of a request.
NutritionOrder.intent RequestIntent Required

Codes indicating the degree of authority/intentionality associated with a request.
NutritionOrder.priority RequestPriority Required

Identifies the level of importance to be assigned to actioning the request.
NutritionOrder.foodPreferenceModifier TypesOfEdibleSubstances Preferred

This value set represents codes for types of edible substances. It include codes from SNOMED CT icon where concept 762766007 Edible Substance (substance) and its sub-concepts, Infant Formula (412413001) and its sub-concepts, Enteral and Supplement Feeds (346415002) and its sub-concepts, Water (11713004), Potable Water (890302005) and its sub-concepts, and Tap Water (444923006).
NutritionOrder.excludeFoodModifier TypesOfEdibleSubstances Preferred

This value set represents codes for types of edible substances. It include codes from SNOMED CT icon where concept 762766007 Edible Substance (substance) and its sub-concepts, Infant Formula (412413001) and its sub-concepts, Enteral and Supplement Feeds (346415002) and its sub-concepts, Water (11713004), Potable Water (890302005) and its sub-concepts, and Tap Water (444923006).
NutritionOrder.oralDiet.type DietCodes Preferred

Codes that can be used to indicate the type of food being ordered for a patient. It includes codes from SNOMED CT icon where concept is Dietary Regime (182922004) and its sub-concepts, Enteral Feeding (229912004) and its sub-concepts, Mixed Breast Milk and Bottle Feeding (35011000087100), Breast Milk Feeding (1297276008), Bottle Feeding of Patient (40043006).
NutritionOrder.oralDiet.schedule.asNeededFor SNOMEDCTMedicationAsNeededReasonCodes Example

This value set includes all clinical findings from SNOMED CT - provided as an exemplar value set.
NutritionOrder.oralDiet.nutrient.modifier NutrientCodes Preferred

NutrientModifier : Codes for types of nutrients that are being modified such as carbohydrate or sodium. This value set includes codes from SNOMED CT icon where concept is-a 226355009 (Nutrients(substance)), and the concepts for Sodium, Potassium and Fluid. This is provided as a suggestive example.
NutritionOrder.oralDiet.texture.modifier CategoriesOfNutritionProducts Preferred

This value set represents codes for categories of nutrition products. It includes all of the codes from the Food Type Modifiers valueset. It include codes from SNOMED CT icon where concept is Breast Milk (226789007) and its sub-concepts, Infant Formula (412413001) and its sub-concepts, Enteral and Supplement Feeds (346415002) and its sub-concepts, Drinks (226465004) and its sub-concepts, Water (11713004), Potable Water (890302005) and its sub-concepts, and 444923006 (Tap Water).
NutritionOrder.oralDiet.texture.type TextureModifiedFoodTypeCodes Example

TextureModifiedFoodType: Codes for types of foods that are texture-modified. This value set is composed SNOMED CT Concepts from SCTID 255620007 Foods (substance) and is provided as a suggestive example.
NutritionOrder.supplement.type SupplementTypeCodes Preferred

SupplementType : Codes for nutritional supplements to be provided to the patient. This value set is composed of SNOMED CT Concepts from SCTID 346415002 (Enteral and supplement feeds (product)).
NutritionOrder.supplement.schedule.asNeededFor SNOMEDCTMedicationAsNeededReasonCodes Example

This value set includes all clinical findings from SNOMED CT - provided as an exemplar value set.
NutritionOrder.enteralFormula.type EnteralFormulaTypeCodes Preferred

SupplementType : Codes for nutritional supplements to be provided to the patient. This value set is composed of SNOMED CT Concepts from SCTID 346415002 (Enteral and supplement feeds (product)).
NutritionOrder.enteralFormula.routeOfAdministration EnteralRouteCodes Extensible

EnteralRouteOfAdministration: Codes specifying the route of administration of enteral formula. This value set is composed of HL7 V3 codes and is provided as a suggestive example.
NutritionOrder.enteralFormula.administration.schedule.asNeededFor SNOMEDCTMedicationAsNeededReasonCodes Example

This value set includes all clinical findings from SNOMED CT - provided as an exemplar value set.
NutritionOrder.additive.modularType EnteralFormulaAdditiveTypeCode Preferred

Codes for modular components to be added to the diet.
NutritionOrder.additive.routeOfAdministration EnteralRouteCodes Extensible

EnteralRouteOfAdministration: Codes specifying the route of administration of enteral formula. This value set is composed of HL7 V3 codes and is provided as a suggestive example.

12.19.4.2 Constraints

UniqueKeyLevelLocationDescriptionExpression
img nor-1Rule (base)Nutrition Order SHALL contain either Oral Diet , Supplement, or Enteral Formula classoralDiet.exists() or supplement.exists() or enteralFormula.exists()

12.19.5 Notes:

12.19.5.1 Enteral continuous vs. intermittent tube feedings

Tube feedings can be administered via continuous drip using a pump or via intermittent feedings, using gravity drip or a pump. The examples Nutrition Order Enteral Bolus Feeding Example and Nutrition Order Enteral Continuous Feeding Example show how this resource can be used to order both kinds of enteral feeding using the structured data elements. The continuous feeding typically specifies rate of administration and a maximum volume of delivery using the enteralFormula.administration.rate and enteralFormula.maxVolumeToDeliver elements. On the other hand, the intermittent feeding typically specifies the amount and frequency of administration using the enteralFormula.administration.quantity and enteralFormula.schedule elements. In both cases, to vary the rate or quantity over time the enteralFormula.administration element can be repeated.

12.19.5.2 Note about the examples

The examples associated with this resource demonstrate the core elements and do not necessarily reflect real-world implementations that may be constrained by future profiles for a given implementation or setting. For example, a renal diet is often comprised of pre-coordinated components including common nutrient modifications such as protein, potassium and phosphorus to assist with the speed of entry of complex diet orders.

12.19.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
additive token Type of module component to add to the diet NutritionOrder.additive.modularType.concept
datetime date Return nutrition orders requested on this date NutritionOrder.dateTime
encounter reference Return nutrition orders with this encounter identifier NutritionOrder.encounter
(Encounter)		 29 Resources
formula token Type of enteral or infant formula NutritionOrder.enteralFormula.type.concept
group-identifier token Composite Request ID NutritionOrder.groupIdentifier
identifier token Return nutrition orders with this external identifier NutritionOrder.identifier 65 Resources
oraldiet token Type of diet that can be consumed orally (i.e., take via the mouth). NutritionOrder.oralDiet.type
patient reference The identity of the individual or set of individuals who requires the diet, formula or nutritional supplement NutritionOrder.subject.where(resolve() is Patient)
(Patient)		 65 Resources
requester reference The identity of the provider who placed the nutrition order NutritionOrder.requester
(Practitioner, PractitionerRole)
status token Status of the nutrition order. NutritionOrder.status
subject reference The identity of the individual or set of individuals who requires the diet, formula or nutritional supplement NutritionOrder.subject
(Group, Patient)
supplement token Type of supplement product requested NutritionOrder.supplement.type.concept