1. Nutrition & Diet Orders
Oral Diets
Qualitative (e.g. texture modifications or gluten-free)
Quantitative (nutrient-level modifications, e.g. 2 gm sodium/day or 1.2 kg protein/kg body weight)
Medical Nutritional Supplements
Enteral/Tube Feedings
Meal Service Requests/Messages
Nutrition Consult Order Requests

2. Types of Diets Oral Diets Medical Nutritional Supplements
Qualitative types
General/Healthful
Age-appropriate modifications, e.g., toddler
Texture/Consistency Modified
Allergy/Intolerance – to eliminate or limit foods with specific ingredients i.e. gluten-free
Quantitative Nutrient-based Modifications
Energy Modified
Carbohydrate Modified
Protein & Amino Acid Modified
Fluid Modified (Restricting or limiting consumption of total fluids)
Mineral Modified (sodium, potassium, phosphorus, etc.)
Medical Nutritional Supplements
Ordered by Generic Description of Product Formulation, e.g., High Protein/2.0 Kcal formula
Ordered by Specific Product/Manufacturer ID
Enteral Nutrition (for tube feedings)
Other Nutrition Orders – Messages/Consults

3. Diet Taxonomy Examples
Fat Modified Diet (Nutrient = Total Fat)
Definition: A diet of known fat composition consistent with the age and life stage of the patient/client
Modifications:
High fat diet (>100 grams of fat) grams oral      
Low fat diet (<30% of energy needs)   oral  
Ketogenic Diet (Nutrient mix/ratio)
Definition: A diet of known fat: protein plus carbohydrate ratio consistent with the age and life stage of the patient/client High fat to protein+carbohydrate ratio (4:1; 3:1) grams oral  
Total Cholesterol
Definition: A diet of known cholesterol composition consistent with the age and life stage of the patient/client   milligrams oral      
High (>250 mg) milligrams oral      
Low (<200 mg) milligrams oral

4. Nutrition Orders Storyboards
New Diet Order for General/Healthful
New Diet Order for multiple quantitative nutrients (Diabetic + Renal dialysis)
New Diet Order for Texture Modifications
Special Case (NPO)
Pediatric (Infant formula)
Enteral/Tube Feeding
Special Meal/Tray Service Requests
(Late Tray or Isolation/Disposables)
Left out on purpose – Out of Scope
--Advance Diet as Tolerated

5. Diet Order Data Elements
The order should contains the following basic information:  
Order ID (to identify this order & for subsequent updates e.g. Cancel ##)
Patient name
Patient identifier
Patient location (unit – room – bed)
Prescriber (who wrote the order)
Date/Time of order (when the order was written/given)
Start Date/Time – May need to be translated into meal periods (e.g. Now or Next Meal period which is Lunch)
Stop Date/Time (Optional – not usual practice for most facilities) 
One or more diet codes (e.g. typically local codes) or
One or more supplement/items (generic user-defined or specific ref codes) – item identifier/name, quantity, unit
Text-notes (messages for meal service)
Family members and guests
Who is allowed to fill out the patient’s menu
Test Messages – Buckets to define these (so we don’t lose interoperable)
e.g. name-value pair

6. FOOD & NUTRITION MGT SYS
DIET ORDER SEQUENCE
MD diet order, supplements, RD consult, VO orders, assigns magmt of TPN or TF others
CPOE or paper chart
EMR
NURSING Order flavor of supplement, VO orders hold diet for test, allergies, late or early tray
HL7 interface
Dietitian input Documentation of care plan, educ. And order labs, TPN and adjusts electrolytes
Diet Clerk food preferences, allergies, intolerances; notifies diet consult, corrects diet order errors; inputs nourishment requests
Conventional Not as much patient contact, less time to identify problems.
EMR = Order Manager (EHR, CPOE )
Limited access for VO or clinical privileges
Limited access for info
FNMS
FOOD & NUTRITION MGT SYS

7. Diet Supplement Flow Chart
Electronic Health Record
Food and Nutrition Management System
ORDER Supplement 1000 Calories per Day
LIC
Order Received and Approved by Provider or Diet Clerk
PAT Role, Service location, Diet Code, Entity
PROV
Order fulfilled with available supplement that meets criteria
Order Resulted
Supplement Provided to Patient
PAT

8. Order Processing Actions (Triggers/States)
Activate Order (start date + time (meal))
Abort Order
Suspend Order
(clinicians have raised concerns)
Held (remove)
Replace Order
Revise Order (needs discussion)
Grey out and remove states not desired (e.g. no Suspend)
New = unverified order
Cancelled (unverified orders)
Nullifed – entered in error (wrong patient)
States are Null to Active
Completed – not expected

9. Application Roles Order Manager - EHR/CPOE/HIS (sending app)
Order Placer
FNMS-Food/Nutrition System (receiving app)
Fullfiller

10. Next Steps to DAM Need a Publishing Facilitator
Additional Roles/Names of Participants
Identify from other DAM
Information Model/Class Diagrams
Conceptual State Machine
Activity Diagrams (Interaction Diagrams)
Functional Requirements
Non-Functional Requirements
Use-Case Bubble Diagrams
For new roles (Diet Clerk) – send Patrick an to forward to publishing to get them added