Mastering the Nutrition Diagnosis: How to write a pass statement in dietetics

According to the British Dietetic Association, consistent documentation using statements like PASS is crucial for demonstrating the impact and effectiveness of dietetic interventions. For dietitians, knowing how to write a pass statement in dietetics is a fundamental skill for summarizing clinical assessments and guiding interventions.

Quick Summary

A successful PASS statement clearly articulates the patient's nutrition problem, its underlying cause, and the evidence collected during assessment. This standardized format, used by dietitians for diagnosis, ensures consistent, high-quality patient care and outcome monitoring.

Key Points

• Understand the P-E-S/P-A-S-S Format: The statement structure is Problem related to Etiology/Aetiology as evidenced by Signs & Symptoms.

• Focus on Nutrition, Not Medicine: The 'Problem' component must be a nutrition diagnosis that a dietitian can influence, not a medical diagnosis like 'Diabetes'.

• Identify the Root Cause: The 'Etiology' is the key to a targeted intervention; it explains the why behind the nutritional problem.

• Use Objective and Subjective Evidence: 'Signs and Symptoms' provides the measurable data (signs) and patient's perspective (symptoms) that proves the diagnosis.

• Ensure Connectivity: All three parts—Problem, Etiology, and Signs/Symptoms—must flow logically and support one another.

• Use Standardized Terminology: Refer to professional guides like the eNCPT for approved terms to ensure consistent, clear documentation.

A clinical dietitian's note, particularly when adhering to the Nutrition Care Process (NCP), relies heavily on a structured nutrition diagnosis statement. While the term 'PASS statement' is used primarily in the UK (Problem, Aetiology, Signs/Symptoms), its US counterpart, the 'PES statement' (Problem, Etiology, Signs/Symptoms), follows the same core format. Mastering this skill ensures clarity, consistency, and professional credibility in all patient documentation.

The Anatomy of a PASS/PES Statement

The statement is a single sentence following a specific formula: [Nutrition Diagnosis/Problem] related to [Etiology/Aetiology] as evidenced by [Signs & Symptoms]. Each of the three components is derived directly from the dietitian's initial nutrition assessment (ADIME: Assessment, Diagnosis, Intervention, Monitoring, Evaluation). Understanding each part is essential for constructing an accurate and actionable diagnosis.

The Problem (P)

This is the specific nutrition-related issue the patient is experiencing. It must be a problem that a dietitian can resolve or improve with a nutrition intervention, not a medical diagnosis. The Academy of Nutrition and Dietetics (AND) provides standardized terminology for these problems within three domains: Intake, Clinical, and Behavioral-Environmental. It is recommended to prioritize intake-related diagnoses when possible, as these are often most directly addressed by a dietitian.

Examples of standardized Problem terms:

• Inadequate oral food/beverage intake
• Excessive energy intake
• Food and nutrition related knowledge deficit
• Swallowing difficulty
• Limited adherence to nutrition-related recommendations

The Etiology (E/A)

This is the root cause or contributing factor of the nutrition problem. It answers the question, 'Why does this problem exist?'. The etiology is a critical part of the statement because the subsequent nutrition intervention should be aimed at addressing this root cause. It requires critical thinking and often involves considering the patient's history, lifestyle, and clinical context. The etiology should be specific and relevant to the dietitian's scope of practice.

Examples of Etiology phrasing:

• ...related to limited food and nutrition related knowledge...
• ...related to dysphagia...
• ...related to impaired skin integrity...
• ...related to self-limitation of food/food group due to food preferences...

The Signs and Symptoms (S)

This section provides the evidence that proves the nutrition problem exists. It consists of measurable and objective data (signs) and patient-reported subjective data (symptoms) gathered during the assessment. Signs and symptoms must directly support the stated problem and etiology. They are crucial for monitoring the effectiveness of the intervention over time and showing tangible progress.

Examples of Signs & Symptoms evidence:

• ...as evidenced by weight loss of 10# in 30 days and estimated energy intake below 50% of estimated needs.
• ...as evidenced by diet recall showing erratic carbohydrate eating pattern, client report of restriction... and elevated HbA1C of 8.9%.
• ...as evidenced by patient's report and observed untouched lunch tray at bedside.
• ...as evidenced by BMI of 40 kg/m$^2$ and estimated energy intake above estimated needs.

Comparison of Effective vs. Ineffective Statements

Aspect	Effective PASS/PES Statement	Ineffective PASS/PES Statement
Problem	Uses specific, standardized nutrition terminology (e.g., 'Inadequate energy intake').	Uses non-specific or medical terminology (e.g., 'Malnutrition').
Etiology	Identifies the root cause the dietitian can address (e.g., 'due to limited access to affordable food').	Blames the patient or uses a non-nutritional cause (e.g., 'due to patient being lazy').
Signs/Symptoms	Includes measurable data and specific patient reports (e.g., 'as evidenced by 10% weight loss in 2 months and patient report of poor appetite').	Uses vague descriptions or external information not in the assessment (e.g., 'as evidenced by patient seems thin').
Focus	Centers on a nutrition diagnosis, distinct from the medical diagnosis.	Confuses nutrition diagnosis with medical diagnosis (e.g., 'Type 2 Diabetes').
Actionability	Leads directly to a clear, targeted nutrition intervention based on the etiology.	Unclear or lacks a direct link to a feasible nutrition intervention.

Steps to Write a Pass/PES Statement

1. Perform a Comprehensive Nutrition Assessment: Gather all relevant data (anthropometric, biochemical, clinical, dietary history). Remember that no new information should appear in the statement that wasn't covered in the assessment.
2. Identify the Nutrition Problem: Based on your assessment, determine the most critical nutrition-related issue. Use standardized language from a resource like the eNCPT terminology manual.
3. Determine the Root Cause (Etiology): Ask 'Why?' or 'What is contributing to this problem?'. It's often helpful to work backward from the problem to find its cause. The etiology must be something the dietitian's intervention can reasonably address or improve.
4. List the Evidence (Signs & Symptoms): What specific data points from your assessment confirm the problem? Pull out the key objective and subjective information. These will serve as your benchmark for monitoring progress.
5. Assemble the Statement: Plug the P, E, and S components into the standard sentence structure. Check that the statement flows logically and that each part is well-supported by your assessment data.

Conclusion

Writing an effective PASS or PES statement is a fundamental skill that underpins the entire Nutrition Care Process. By accurately summarizing a patient's nutrition problem, its root cause, and the supporting evidence, dietitians create a clear, actionable plan for intervention. This standardized approach not only improves communication between healthcare professionals but also provides a systematic method for monitoring and evaluating patient outcomes, ultimately improving the quality of care. For further guidance and access to the official standardized terminologies, dietitians can refer to professional resources like the Academy of Nutrition and Dietetics and the British Dietetic Association.

Tips for refining your statements

• Use information gathered in the assessment to determine the nutrition problem.
• The nutrition diagnosis should be one that a dietitian can address, at least in part.
• Prioritize intake-related diagnoses over others, as they are most directly impacted by nutrition intervention.
• Ensure a logical connection between the Problem, Etiology, and Signs/Symptoms.
• Keep it concise; avoid including multiple unrelated problems in a single statement.

Example PES Statement

• Patient Profile: 55-year-old male with a new diagnosis of Type 2 Diabetes.
• Assessment Data: Reports consuming large volumes of sugary drinks (approx. 2 liters/day). Lacks prior education on carbohydrate management. HbA1c is 8.9%.
• PES Statement: Food and nutrition related knowledge deficit related to no prior diabetes nutrition-related education as evidenced by client report of frequent sugary drink consumption and elevated HbA1c of 8.9%.

Frequently Asked Questions

What is the difference between a PES and a PASS statement?

A PES statement (Problem, Etiology, Signs/Symptoms) is the term used in the US by the Academy of Nutrition and Dietetics, while a PASS statement (Problem, Aetiology, Signs/Symptoms) is the equivalent term used in the UK by the British Dietetic Association.

Why is it important to use standardized terminology in a PES/PASS statement?

Using standardized terminology ensures clarity, consistency, and professional communication among healthcare providers. It helps dietitians accurately describe nutritional problems and interventions, ensuring everyone understands the patient's nutritional care plan.

How do you avoid confusing a medical diagnosis with a nutrition diagnosis?

A medical diagnosis is a disease or condition (e.g., heart disease), while a nutrition diagnosis describes a nutritional problem a dietitian can treat (e.g., excessive energy intake). Focus on the dietary and nutritional aspects you can address directly with your intervention.

What if there are multiple nutrition problems?

If a patient has multiple nutrition-related issues, it is recommended to write separate PES/PASS statements for each problem. This ensures that each issue is documented individually and can be monitored for resolution.

What role does the nutrition assessment play in writing a PES/PASS statement?

The nutrition assessment is the critical first step. All information used in your PES/PASS statement—the Problem, Etiology, and Signs/Symptoms—must be derived from and supported by the data you collect during your assessment.

Can the etiology be a medical condition?

While a medical condition can be a contributing factor, the etiology should focus on the root cause that the dietitian can influence. For example, instead of 'related to cancer,' you might write 'related to decreased appetite from chemotherapy'.

What kind of evidence should be included in the signs and symptoms section?

This section should include a combination of measurable, objective data like lab results, weight changes, and estimated intake, as well as subjective data like the patient's reported symptoms or difficulties.