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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of
University of Wisconsin Hospital and Clinics and University of Wisconsin Medical Foundation.
Policy Title: Therapeutic Diet Manual
Policy Number: 3.01
Effective Date: March 1, 2016
Chapter: Culinary and Clinical Nutrition Services
To ensure a therapeutic diet manual is appropriately approved and implemented as directed by Medicare's
Conditions of Participation for Hospitals Section 482.28 ("A current therapeutic diet manual approved by
the dietitian and medical staff must be readily available to all medical, nursing and food service
personnel") and The Joint Commission Accreditation Standards.
Therapeutic diet manual is an evidence-based electronic nutrition care manual used to prepare diets that
meet specific nutrition needs and/or diet orders that are prescribed by healthcare professionals.
The Nutrition Care Manual (NCM) is a web-based resource for the nutrition care of adults and is
purchased by Culinary and Clinical Nutrition Services.
The Pediatric Nutrition Care Manual (PNCM) is a web-based resource for the nutrition care of pediatrics
and is purchased by Culinary and Clinical Nutrition Services.
Nutrition Committee is a sub-committee of the University Hospitals and Clinics Medical Board and has
multidisciplinary with representation from the medical staff, clinical nutrition services, pharmacy service,
nursing service, clinical laboratory medicine, and culinary services.
CBORD is the software database used to ensuring accurate monitoring and safety of all food items used
in a food venue.
Health Link is the electronic medical record used by the organization.
A. The Academy of Nutrition and Dietetics Nutrition Care Manual (NCM) and the Academy of
Nutrition and Dietetics Pediatric Nutrition Care Manual (PNCM) are the approved diet manuals
for University of Wisconsin Hospitals and Clinics.
1. The therapeutic diet manual is reviewed and approved annually by the Nutrition
a. Document approval is obtained in the meeting minutes and kept on file in the
Medical Board Administration.
b. Signatures are obtained on the NCM and PNCM approval form, which is
scanned and posted on the Clinical Nutrition Services intranet site.
2. The manual is available on U-Connect for all UW Health users and is also available
through Health Link resources.
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3. A back-up NCM and PNCM CD-ROM are provided to each subscriber from
B. Terminology used for diet nomenclature and prescribed diet orders are evidence based and
consistent across all food venues.
a. Foods reflect these standards for nutrition and are planned in accordance with Additions
and modifications are discussed with medical staff.
C. Each food venue is responsible for ensuring that food and beverages offered on therapeutic diets
meet the specified guidelines outlined in the therapeutic diet manual and are planned in
accordance with the Dietary Reference Intakes (DRI) of the Food and Nutrition Board, National
Research Council of the National Academy of Sciences by:
1. Adding all food items for therapeutic diets to the CBORD database prior to use.
2. Ensuring the food item used in the recipe is the food item that is being purchased,
currently stock item, and found in the CBORD database.
3. Performing quality assurance monitoring and testing.
D. General guidelines for parenteral and enteral nutrition and infant/pediatric/adult nutrition
formulary are available in the NCM and PNCM with specific organizational practice guidelines
found on U-Connect under the Clinical Practice Guidelines.
A. Comprehensive Accreditation Manual for Hospitals: Official Handbook, Joint Commission on
Accreditation of Healthcare Organizations (PC. 4.10, PC. 5.50, PC. 7.10, and LD. 3.30)
B. Medicare Condition of Participation for Hospitals, Section 482.28
C. Academy of Nutrition and Dietetics Pediatric Manual of Clinical Dietetics (web based)
D. Academy of Nutrition and Dietetics Nutrition Care Manual (web based)
E. Dietary Reference Intakes, Food & Nutrition Board, National Academy of Sciences, National
Research Council, 1997-2004
F. Manual of Clinical Nutrition Management, Compass Group, 2013.
Sr. Management Sponsor: VP, Facilities and Support Services
Author: Director, Culinary & Clinical Nutrition Services
Approval Committee: UW Health Administrative Policy and Procedure Committee
President, University of Wisconsin Hospitals
Chief of Clinical Operations
Next revision: 022019