The Quality Management and Government Relations Teams in consultation with the Commission on Dietetic Registration and ADA Legal Counsel crafted a response to a question posted on the Clinical Nutrition Management DPG electronic mailing list in November 2005. This response was posted on that DPG EML, as well as, on DieteticsL. You are encouraged to share this information with members and can be posted on various EMLs and Web sites to assist practitioners.

Also, as you review the following information, please keep in the following two points:

1. ADA has initiated an article about this issue to be published in the Journal of the American Dietetic Association this summer. This article will include all pertinent and current information that you need to manage the various situations in which RDs supervise non-RDs in a clinical setting. It is ADA’s goal to put all of this information in one place for you as a resource to accompany the facility-specific procedures that you share with one another; and
   
   
2. The following briefly addresses the specific question that was raised in November about registration-eligible employees’ documentation in the medical record and separate job descriptions. This is a clarification/update to information that you would have received from ADA in the past - Please see below.

We recently hired a graduate of an approved dietetic internship program and contacted the ADA (to ask) how she should sign charts. …I was wondering if any one has created an "interim" job description and competencies such as they describe and would you be willing to share? (CNM Listserv® November 2005)

 

• The credentials or qualifications necessary for the person who documents nutrition care in the medical record will be determined by the particular state and facility.[1] Generally, the individual must be a “qualified dietitian”, which does not always need to be an RD.

• Neither the Centers for Medicare & Medicaid Services (CMS) nor the Joint Commission (JCAHO), which has adopted the CMS standards, require a “qualified dietitian” to be an RD. Qualifications are generally determined on the basis of “education, experience, specialized training, state licensure or registration when applicable, and maintaining professional standards of practice.” (CMS State Operations Manual (SOM))

• A particular state or facility may, however, require that a dietitian must be an RD or be licensed, or both, in order to be qualified. It is also possible that the new graduate might be adequately qualified to document nutrition care in the medical record. Managers of clinical nutrition services should refer to the state licensure law and state regulations that apply to the facility.

• In some states or facilities, nutrition care responsibilities may be assigned to a new graduate or registration-eligible employee who works under the supervision of an RD. In such cases, a good practice is to ensure that the employee’s personnel record confirm that she/he is competent to perform all assigned tasks until all credentialing requirements are met.

• As to how nutrition care documentation in a medical record should be signed, a new graduate or registration-eligible individual should use a title that is accurate and not misleading. The Commission on Dietetics Registration does not specify how nutrition care documentation in the medical record should be signed, but advises that the term RDE is not a professional credential and should not be used.

• In summary, the new graduate, if properly qualified, may sign the chart if neither the state nor the facility requires RD credential for documentation of nutrition care in the medical record. The safest policy, if clarification of applicable regulations and facility policy cannot be obtained, is for an RD to co-sign the notes of a new graduate or registration-eligible employee.

• From a management standpoint, there should be clear job descriptions consistent with the facility policies for all members of the clinical nutrition staff, as well as satisfactory documentation of their competency. If these are in place, state or accrediting organizations should be satisfied. This is not an issue only about credentials, but also about good management practices.

• Since each facility is unique in how it might choose to interpret CMS and state regulations, it is advisable to review your policies with the Compliance or Risk Management and Human Resources offices of your facility.

As a matter of relevance to this discussion, please note that following phrase within the Key Considerations for the definition of Registered Dietitian in the ADA Scope of Dietetics Practice Framework Definition of Terms is in the process of being deleted:

“It is only after successfully passing the exam that the individual would meet the criteria outlined in the standards and elements of performance JCAHO relative to *qualified individual. *Qualified individual - an individual or staff member who is qualified to participate in one or all of the mechanisms outlined in Joint Commission standards by virtue of the following: education, training, experience, competence, registration or certification; or applicable licensure, law, or regulation.”

Deletion of the above is occurring because:

1. It suggests that JCAHO is the only healthcare facility accreditation organization and it is not (e.g., there is also Healthcare Facilities Accreditation Program (HFAP)); and
   
   
2. The wording is misleading in suggesting that only RDs can be “qualified individuals” under JCAHO standards when that is, as discussed above, clearly not the case.

 

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[1] Assuming you work in a hospital, there are three resources that will determine the appropriate answer to this question in your facility. These are:

1. The Centers for Medicare & Medicaid Services (CMS) Hospital Conditions of Participation (CoP) that establish the minimum quality and safety requirements for a hospital to be certified to receive payment under Medicare Part A and Medicaid. The Hospital CoP are part of the CMS State Operations Manual (SOM), Appendix A, for surveyors.

2. Your state’s regulations for hospital licensing (often referred to as “Administrative Code” or rules).

3. Your facility’s and department’s job descriptions and policies and procedures.

(posted 4/12/06)

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