Therapeutic Diet Orders: State Status and Regulation

Map of United States with States color-coded for TDO status

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The information below is a resource for Academy members considering seeking privileges to order therapeutic diets in the hospital setting. We have sought to identify all relevant statutes and regulations related to therapeutic diet ordering in each state and provide a brief analysis of each state’s relevant law. In the event that state regulators perceive additional statutes or regulations to be relevant, we are available to work with affiliates. We encourage RDNs to become familiar with their relevant state regulations and statutes, including the interpretation of the extent of their scope of practice.

States are color coded in a stoplight fashion to indicate:

Green:
There do not appear to be statutory or regulatory impediments to qualified RDNs seeking hospital privileges to order therapeutic diets.

Yellow:
There are not definitive impediments to obtaining privileges. However, certain statutory or regulatory language exists leading us to recommend affiliates work with state regulators to ensure their interpretation of relevant statutes and regulations will enable qualified RDNs to see privileges for therapeutic diet.

Red:
Specific statutory or regulatory impediments exist that preclude RDNs from taking full advantage of the opportunities presented by the revised CMS rule.


The Academy will be working with affiliate leaders to remove existing impediments through statutory or regulatory changes.

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

 


Alabama

Status: Red

Licensure:

Section 5 of the Alabama licensure act permits broad authorities for RDNs "upon referral or directive of a licensed physician."

Hospital Regulations:

420-5-7-.14 (3)(a): "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients."

Recommendation:

The hospital regulations for therapeutic diets track the prior version of the CMS rule and likely need to be revised to align with the new rule. Given existing Alabama regulatory language for hospitals, 420-5-7-.14(3)(a) could appropriately be revised to "All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian as authorized by the medical staff."

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Alaska

Status: Yellow

Licensure:

None

Hospital Regulations:

7 AAC 12.720(a): "A facility that provides dietetic services, with the exception of frontier extended stay clinics, must comply with the provisions of this section. (b) Except as provided in (p) and (q) of this section, a facility must employ (1) a full-time dietitian who is registered by the American Dietetic Association;"

7 AAC 12.720(d): "The dietetic service must provide food of the quality and quantity to meet the patient's needs in accordance with physician's orders and, to the extent medically possible, to meet the National Research Council's Recommended Dietary Allowances, 10th edition (1989), adopted by reference."

Recommendation:

Given the requirement that the dietetic service must be in accordance with the physician's orders we recommend working with the Alaska Department of Health and Social Services, Health Facilities Licensure to determine whether 7 AAC 12.720 would allow RDNs to order therapeutic diets and if not, to revise it to align with the new CMS rule.

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Arizona

Status: Green

Licensure:

None

Other Legislation:

36-416.(A) "A hospital that is licensed pursuant to section 36-422 may allow a registered dietitian or other qualified nutrition professional to order diets, enteral feeding, nutritional supplementation or parenteral nutrition if authorized by medical staff pursuant to 42 Code of Federal Regulations section 482.28(b) and if both:

  1. The hospital's written policies and procedures allow registered dietitians or other qualified nutrition professionals to issue such orders.
  2. The hospital has written policies and procedures that address the hospital's response to adverse events, if any, that arise as a result of orders issued by a registered dietitian or other qualified nutrition professional."

Hospital Regulation:

R-9-10-231(5): "Dietary services are provided under the direction of an individual qualified to direct the provision of dietary services according to hospital policies and procedures;"

R-9-10-231(9): "A medical staff member documents an order for a diet for each patient in the patient's medical record;"

Recommendation:

While the hospital regulations remain in place, they are superseded by the language of SB1327. For legal clarity, we recommend working with the Arizona Dept. of Health Services, Office of Medical Facilities to clarify the meaning of the regulation and perhaps revise R-9-10-231(9) to: "A medical staff member or qualified registered dietitian as authorized by the medical staff documents an order for a diet for each patient in the patient's medical record;"

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Arkansas

Status: Green

Licensure:

None

Hospital Regulations:

Section 17 (A)(9): "Diets shall be in writing and signed by a physician or a mid-level practitioner if privileged by the Medical Staff and Governing Body. Dietitians may issue orders for patient diets if authorized by the medical staff. Notification according to facility policy shall be made to the Nutrition Services Department on a timely basis, kept current and include current date, the patient's name, room number and diet order."

Clinical dietitian/nutritionist "Shall be a registered dietitian, or registry eligible, and evaluate and oversee the delivery of effective nutritional care based on current, recognized nutritional practices Section 17(D)(1)."

Section 17(D)(3)(b)(v) notes: "The patient care plan shall include … Any requests for alterations or modifications to the ordered diet's nutrient content, consistency, administration route/method or meal pattern as served in the hospital in order to meet the nutritional needs and/or special feeding needs of the patient."

Rules and Regulations for Hospitals and Related Institutions in Arkansas

Recommendation:

Arkansas does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

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California

Status: Red

Licensure:

2586(a): "Notwithstanding any other provision of law, a registered dietitian, or other nutritional professional meeting the qualifications set forth in subdivision (e) of Section 2585 may, upon referral by a health care provider authorized to prescribe dietary treatments, provide nutritional and dietary counseling, conduct nutritional and dietary assessments, and develop nutritional and dietary treatments, including therapeutic diets, for individuals or groups of patients in licensed institutional facilities or in private office settings."

2586(g): "For purposes of this section, "health care provider" means any person licensed or certified pursuant to this division, or licensed pursuant to the Osteopathic Initiative Act or the Chiropractic Initiative Act."

Hospital Regulations:

Section 70055: "Dietitian. Dietitian means a person who is registered or eligible for registration as a registered dietitian by the American Dietetic Association." Section 70271 "Dietetic service means providing safe, satisfying and nutritionally adequate food for patients with appropriate staff, space, equipment and supplies."

Section 70273(a): "The dietetic service shall provide food of the quality and quantity to meet the patient's needs in accordance with physicians' orders..."

Section 70273(b): "Policies and procedures shall be developed and maintained in consultation with representatives of the medical staff, nursing staff and administration to govern the provision of dietetic services. Policies shall be approved by the medical staff, administration and governing body. Procedures shall be approved by the medical staff and administration."

Section 70273(e): "Therapeutic diets shall be provided as prescribed by a person lawfully authorized to give such an order and shall be planned, prepared and served with supervision and/or consultation from the dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary."

Recommendation:

Given the requirement that the dietetic service must be in accordance with the physician's orders we recommend working with the California regulators to determine whether California will allow RDNs to order therapeutic diets and if not, to revise it to align with the new CMS rule. Caution is also urged given the language in section 2586(g) defining "health care provider" as someone licensed or certified and the language in 2586(a) regarding who is authorized to prescribe therapeutic diets.

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Colorado

Status: Red

Licensure:

None

Hospital Regulations:

6 CCR 1011-1 Chap 04 Part 16.101(3): "A registered dietitian shall be responsible for the nutritional aspects of care, including but not limited to, the evaluation of the nutritional status and needs of patients, the review of modified and special diets for nutritional adequacy, and patient counseling." 16.102(1)(a) "The nutritional needs of the patients shall be met in accordance with recognized dietary standards and in accordance with orders of the licensed independent practitioners responsible for the care of the patient."

16.102(1)(c): "Therapeutic diets and nourishments shall be served as prescribed by the attending licensed independent practitioner."

Recommendation:

Colorado's Standards for Hospitals and Health Facilities (6 CCR 1011-1 Chap 04) Part 16 contains language for therapeutic diets similar to the prior version of the CMS rule and may need to be revised to align with the new rule. Given existing Colorado regulatory language for hospitals and the requirement that a registered dietitian is "responsible for the nutritional aspects of care" under 16.101(3), 16.102(1)(a) could be revised to the effect of "The nutritional needs of the patients shall be met in accordance with recognized dietary standards and in accordance with orders of the licensed independent practitioners responsible for the care of the patient or qualified registered dietitians as authorized by the medical staff." Part 16.102(1)(c) could be revised to "Therapeutic diets and nourishments shall be served as prescribed by the attending licensed independent practitioner or qualified registered dietitian as authorized by the medical staff."

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Connecticut

Status: Green

Licensure:

Chapter 384b Sec. 20-206m(5): "'Dietetics or nutrition practice' means the integration and application of the principles derived from the sciences of nutrition, biochemistry, food, physiology, and behavioral and social sciences to provide nutrition services that include: (A) Nutrition assessment; (B) the establishment of priorities, goals, and objectives that meet nutrition needs; (C) the provision of nutrition counseling in health and disease; (D) the development, implementation and management of nutrition care plans; and (E) the evaluation and maintenance of appropriate standards of quality in food and nutrition. The term "dietetics or nutrition practice" includes the ordering of oral diets and enteral and parenteral nutrition support and the physical administration of oral diets, but does not include the administration of nutrition by any route other than oral administration, the administration of enteral or parenteral diets or the issuance of orders for laboratory or other diagnostic tests or orders intended to be implemented by any person licensed pursuant to chapter 378."

Sec. 20-206q. "Orders for a patient diet. A certified dietitian-nutritionist may write an order for a patient diet, including, but not limited to, a therapeutic diet for a patient in an institution, as defined in section 19a-490. The certified dietitian-nutritionist shall write such order in the patient's medical record. Any order conveyed under this section shall be acted upon by the institution's nurses and physician assistants with the same authority as if the order were received directly from a physician. Any order conveyed in this manner shall be countersigned by a physician within seventy-two hours unless otherwise provided by state or federal law or regulations. Nothing in this section shall prohibit a physician from conveying a verbal order for a patient diet to a certified dietitian-nutritionist."

Certification Statute

Hospital Regulations:

No pertinent regulations identified.

Hospitals, Child Day Care Centers, Other Institutions and Children's General Hospitalsa>

Recommendation:

Connecticut does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

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Delaware

Status: Green

Licensure:

§ 3802: "Definitions. … Scope of Practice: … (e) Interpreting and recommending interventions to meet nutrient needs relative to individual health status, including but not limited to medically prescribed diets, tube feedings and specialized intravenous solutions."

Dietitian/Nutritionist Licensure Act

Hospital Regulations:

None found to date other than a bill to amend Section 1164: "Every residential health facility must at all times provide nutrition and dietetics staffing adequate to meet the care needs of each resident. The staffing level must, at a minimum, include a full-time food service manager. Any food service manager hired after July 1, 2001 must be a registered dietitian or a certified dietitian/nutritionist, a registered dietetic technician, a certified dietary manager, or must have a Bachelor of Science or associate degree in food service management or related field. The educational requirements shall be met provided that if an insufficient pool of applicants exists, other qualifications may be deemed acceptable in accordance with regulations promulgated by the Department. A sub-acute transitional care unit of an acute care hospital, with 30 beds or fewer, is exempt form [sic] the provisions of this subsection provided that other licensed personnel perform the duties of this function."

Hospital Standards (Construction, Maintenance, and Operation)

Recommendation:

According to the Director, Office of Health Facilities Licensing and Certification, "The Delaware hospital regulations do not include any language that would preclude a RDN from performing this task"

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District of Columbia

Status: Yellow

Licensure:

§ 3–1201.02. (6)(A) "Practice of dietetics and nutrition" means the application of scientific principles and food management techniques to assess the dietary or nutritional needs of individuals and groups, make recommendations for short-term and long-term dietary or nutritional practices which foster good health, provide diet or nutrition counseling, and develop and manage nutritionally sound dietary plans and nutrition care systems consistent with the available resources of the patient or client."

Definitions of Health Occupations

Hospital Regulations:

22-B2028: "Each hospital shall provide for the daily nutritional needs of all patients, including the provision of any diets ordered by a medical practitioner."

Recommendation:

Because hospitals in the District of Columbia are one of the few facilities that do not specify that therapeutic diets must be prescribed by a physician, we recommend confirming with the DC Department of Health that there are no hospital regulations that preclude hospitals from privileging qualified RDNs from independently ordering therapeutic diets.

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Florida

Status: Green

Licensure:

468.516: "Practice requirements. (1)(a) A licensee under this part shall not implement a dietary plan for a condition for which the patient is under the active care of a physician licensed under chapter 458 or chapter 459, without the oral or written dietary order of the referring physician. In the event the licensee is unable to obtain authorization or consultation after a good faith effort to obtain it from the physician, the licensee may use professional discretion in providing nutrition services until authorization or consultation is obtained from the physician. … (3) This section does not preclude a licensed dietitian/nutritionist from independently ordering a therapeutic diet if otherwise authorized to order such a diet in this state. "

Hospital Regulations:

59A-3.065 Definitions (44) "'Registered dietitian' means one who meets the standards and qualifications established by the Commission on Dietetic Registration of the Academy of Nutrition and Dietetics and is currently registered with the Academy of Nutrition and Dietetics.

59A-3.2085 Department and Services.
(repeated verbatim in 59A-3.240)
59A-3.240 Nutritional Services.
(1)(c) "…a registered dietitian shall provide at least the following services to the hospital on the premises on a regularly scheduled basis: … 3. Approval of menus and modified diets;

(7) Personnel in the dietetic department shall receive, as appropriate to their level of responsibility, instruction in: …
(f) The writing of modified diets and the recording of pertinent dietetic information in the patient's medical record.

(9) Written dietetic policies shall include at least the following: …
(b). A requirement that diet orders be recorded in the patient's medical record by an authorized individual before the diet is served to the patient. …
(j) The role of the dietetic department in the preparation, storage, distribution and administration of enteric feeding, tube feeding and total parenteral nutrition programs.
(k) Alterations in diets or diet schedules, including the provision of food service to patients who do not receive regular meal service. …

(18) Dietetic services shall be provided in accordance with written orders by the health professional responsible for the patient and appropriate information shall be recorded in the patient's medical record. …

(19) Within 24 hours of admission and within 24 hours of any subsequent orders for diet modification, the diet order shall be confirmed by the practitioner responsible for the patient receiving oral alimentation.

Hospital Licensure Rules

No pertinent regulations identified.

Recommendation:

Florida does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

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Georgia

Status: Yellow

Licensure:

None

Hospital Regulations:

111-8-40-.23(c)(3): "Therapeutic diets shall be prescribed by the member of the medical staff responsible for the care of the patient."

Recommendation:

Georgia regulations will currently allow qualified RDNs to order therapeutic diets if they are appointed to the medical staff and determined to be "responsible for the care of the patient," but a regulatory change will be required to otherwise allow qualified RDNs to be privileged to order therapeutic diets without becoming a member of the medical staff or without being responsible for the care of the patient.

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Hawaii

Status: Red

Licensure:

None

Hospital Regulations:

§11-93-8(c): "All modified diets shall be: (1) Prescribed by the patient's physician with a record of the diet as ordered kept on file."

§11-93-8(d): "Therapeutic diets shall be planned by a qualified dietitian, as prescribed by the patient's physician."

§11-93-51: "'Dietitian' means a person who: (1) Is registered by the American Dietetic Association under its requirements in effect on the day of publication of this provision; or (2) Is eligible for examination to become a registered dietitian."

Hospital Regulations

Recommendation:

Hawaii hospital regulations appear to need to be revised to reflect the changes in the new CMS rule to the effect of: §11-93-8(c) "All modified diets shall be: (1) Prescribed by the patient's physician or qualified dietitian privileged by the hospital to do so with a record of the diet as ordered kept on file;" and §11-93-8(d) "Therapeutic diets shall be planned by a qualified dietitian, as prescribed by the patient's physician or qualified dietitian privileged by the hospital to do so."

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Idaho

Status: Red

Licensure:

None

Hospital Regulations:

16.03.14(002)(11): "Dietitian (Qualified Consultant). A person who: (12-31-91) a. Meets the requirements for registration by the Commission on Dietetic Registration of the American Dietetic Association under its requirements in effect on March 9, l976; or (10-14-88) b. Has a baccalaureate degree with major studies in food and nutrition or dietetics, has one (1) year of supervisory experience in the dietetic service of a health care institution, and participates annually in continuing dietetic education."

16.03.14(320)(06): "Modified Diets. All diets, including general diets, shall be ordered by the attending physician."

Hospital Regulations

Recommendation:

Idaho hospital regulations appear to need to be revised to reflect the changes in the new CMS rule to the effect of: 16.03.14(320)(06) "Modified Diets. All diets, including general diets, shall be ordered by the attending physician or qualified dietitian privileged by the hospital to do so."

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Illinois

Status: Green

Licensure:

Illinois limits the provision of enteral and parenteral nutrition to a subset of licensed dietitian nutritionists.

Hospital Regulations:

Section 250.1610(b): "The dietetic department shall be directed by a full-time person who is qualified by dietetic and food service management training and experience, preferably a registered dietitian, whose responsibilities shall include, but are not limited to, the following: 1) developing written policies and procedures to include but not necessarily be limited to: . . . C) medically prescribed diet orders and alterations in diets or diet schedules such as holding trays, late trays, and times for accepting diet changes;"

Section 250.1630(b): "Menus shall be planned, and followed, to meet the nutritional needs of patients in accordance with physicians' orders. . ."

Section 250.1640(a): "All diets shall be ordered by the patient's attending physician and/or a registered dietitian with the attending physician's confirmation. Diet orders shall be recorded in the patient's medical chart. (b) All diet orders shall be sent to the dietetic service department in writing.  Each diet order shall have sufficient pertinent information to enable the dietetic service to serve the diet as prescribed by the physician."

Section 250.1660: This section ("Therapeutic (Modified) Diets") contains no specific restriction as to the practitioner able to order therapeutic diets.

Recommendation:

Illinois does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

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Indiana

Status: Green

Licensure:

IC 25-14.5-1-10: Definition of medically prescribed diet requires them to be "performed as initiated by or in consultation with a physician. . ."

Hospital Regulations:

A0536: (d) "Menus shall meet the needs of the patients as follows: (1) Therapeutic diets shall be prescribed by the practitioner responsible for the care of the patient or by a qualified dietitian as authorized by the medical staff."

Hospital Licensure Rules

Recommendation:

Indiana does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

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Iowa

Status: Green

Licensure:

None

Hospital Regulations:

481-51.20(2)(b): "The food service shall provide food of the quality and quantity to meet the patient’s needs in accordance with the qualified health practitioner’s orders . . ."

5120(2)(e): "Therapeutic diets shall be provided as prescribed by the qualified health care practitioner, including a registered, licensed dietitian, and shall be planned, prepared, and served with supervision or consultation from the registered, licensed dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food to make appropriate substitutions when necessary."

Recommendation:

Iowa does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

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Kansas

Status: Yellow

Licensure:

None

Hospital Regulations:

K.A.R. § 28-34-1a(f): "'Dietitian' means a person who is licensed in Kansas as a dietitian."

28-34-14(d): "The food and nutritional needs of patients shall be met with the recommended dietary allowance of the food and nutrition board of the national research council and in accordance with physician's orders."

Hospital Regulations

Recommendation:

Given the requirement that the dietetic service must be in accordance with the physician's orders, we recommend working with Kansas regulators to ascertain whether Kansas would allow RDNs to order therapeutic diets and if not, to revise it to align with the new CMS rule.

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Kentucky

Status: Green

Licensure:

None

Hospital Regulations:

902 KAR 20:016 Section 1(10): "Registered, certified or registry-eligible dietician" means a person who is certified in accordance with KRS Chapter 310."

Section 11(b)(7): "Orders for diet, diagnostic tests, therapeutic procedures, and medications, including patient limitations, signed and dated by the medical staff member or other ordering personnel acting within the limits of their statutory scope of practice"

Section 4(3)(5):
(b) "Nutritional needs shall be … in accordance with the medical staff member's orders."
(d): "Every diet, regular and therapeutic, shall be prescribed in writing, dated, and signed by the attending medical staff member or other ordering personnel acting within their statutory scope of practice. Information on the diet order shall be specific and complete and shall include the title of the diet, modifications in specific nutrients stating the amount to be allowed in the diet, and specific problems that may affect the diet or eating habits."

Recommendation:

Kentucky does not appear to have any impediments to qualified RDNs seeking hospital privileges to order therapeutic diets.

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Louisiana

Status: Green

Licensure:

Section 3083 (2): "'Licensed dietitian/licensed nutritionist' means a person licensed under this Chapter."

Board of Examiners in Dietetics and Nutrition Practice Act

Section 103 of Louisiana's rules define Nutritional Assessment as "the evaluation of the nutritional needs of individuals and groups based upon appropriate biochemical, anthropometric, physical and dietary data to determine nutrient needs including enteral and parenteral nutrition regardless of setting, including but not limited to ambulatory settings, hospitals, nursing homes and other extended care facilities."

Hospital Regulations:

§9303: "Registered Dietitian―a dietitian who is qualified based on registration by the Commission on Dietetic Registration of the American Dietetic Association and licensing by the Louisiana Board of Examiners in Dietetics and Nutrition."

§9379(A): "Food and dietetic services shall be under the supervision of a registered dietitian, licensed to practice in Louisiana, who is employed either full time, part time or on a consulting basis."

§9381(B) Menus & Therapeutic Diets: "Therapeutic diets shall be prescribed by the licensed practitioner(s) responsible for the care of the patient. Therapeutic diets, and laboratory tests to monitor the effectiveness of the dietary plan, may be prescribed by a licensed dietitian/ nutritionist subject to the approval of, and authorization by, the facility's medical staff or bylaws and in accordance with state law. Each patient's nutritional intake shall be documented in the patient's medical record. Nutritional intake includes both enteral and parenteral nutrition."

Recommendation:

Louisiana does not appear to have any impediments to qualified RDNs seeking hospital privileges to order therapeutic diets.

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Maine

Status: Green

Licensure:

None

Hospital Regulations:

No pertinent regulations identified.

Recommendation:

Maine's Department of Health and Human Services reports that they do not have independent regulations for Food and Dietetic Services (1.5.6), but instead abide by federal CMS Conditions of Participation. Thus, RDNs in Maine should feel comfortable working with their hospitals to obtain privileges to independently order therapeutic diets in Maine. (Contact Mike Swan at Maine's DHHS with any concerns about Maine's state hospital regulations.)

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Maryland

Status: Green

Licensure:

None

Hospital Regulations:

None

Acute General Hospitals and Special Hospitals

Recommendation:

Maryland does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

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Massachusetts

Status: Green

Licensure:

None

Hospital Regulations:

No pertinent regulations identified.

Recommendation:

Massachusetts does not appear to have any impediments to qualified RDNs seeking hospital privileges to order therapeutic diets.

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Michigan

Status: Red

Licensure:

None

Hospital Regulations:

R 325.1027 Rule 27(c): "No medication or treatment shall be given to any patient except on the written order of the physician."

Recommendation:

Contact the Michigan Academy of Nutrition and Dietetics – members of their Public Policy Panel for latest update.

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Minnesota

Status: Green

Licensure:

None

Hospital Regulations:

4640.2800 Subpart 1. Supervision: "The dietary department shall be under the supervision of a trained dietitian or other person experienced in the handling, preparation, and serving of foods; in the preparation of special diets; and in the supervision and management of food service personnel."

Recommendation:

Community residential settings allow a "person's physician or dietitian" to prescribe special dietary needs. There does not appear to be an impediment in Minnesota.

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Mississippi

Status: Yellow

Licensure:

Rule 3.1.3 (11): "'Medical nutrition therapy' is a nutritional diagnostic therapy and counseling services for the purpose of disease management. …

a. Therapy ranges from diet modification and nutrition counseling to administration of specialized nutrition therapies, such as intravenous medical nutritional products as determined necessary to manage a condition or treat illness or injury.

b. Administration of specialized nutrition therapies does not include the clinical aspects of insertion of the nasogastric tube, initiation of the intravenous line, nor administration of nutritional feedings/fluids or medications via the intravenous, nasogastric, or gastrostomy route."

Thus, Mississippi regulations limit the ability to insert nasogastric tubes or initiate intravenous lines.

Hospital Regulations:

Rule 41.52.1: All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) responsible for ordering, providing, or evaluating the service furnished. All orders/entries must be dated, timed, and authenticated promptly by the prescribing physician or another physician responsible for the care of the patient, even if the order did not originate with him or her.

Recommendation:

Although there are no clear impediments to RDNs in Mississippi pursuing privileges to order therapeutic diets, we encourage consultation with Mississippi regulators regarding the language related to the authentication of orders and how that may impact the ordering process.

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Missouri

Status: Yellow

Licensure:

None

Hospital Regulations:

19 CSR 30-20.011(28): "Qualified dietitian—An individual who is registered by the Commission on Dietetic Registration of the American Dietetic Association or who has the documented equivalent in education, training and experience, with evidence of relevant continuing education."

19 CSR 30-20.090(9): "Menus shall be planned, written and followed to meet the nutritional needs of the patients as determined by the recommended dietary allowances (RDA) of the Food and Nutrition Board of the National Research Council, National Academy of Sciences or as modified by physician's order."

Division of Regulation and Licensure, Hospitals

Recommendation:

The hospital regulations for therapeutic diets may need to be revised to align with the new rule. Given existing Missouri regulatory language for hospitals, section 19 CSR 30-20.090(9) could be appropriately revised to "Menus shall be planned, written and followed to meet the nutritional needs of the patients as determined by the recommended dietary allowances (RDA) of the Food and Nutrition Board of the National Research Council, National Academy of Sciences or as modified by physician’s order or orders from a qualified dietitian as authorized by the medical staff."

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Montana

Status: Green

Licensure:

None

Hospital Regulations:

37.106.1124(1)(c) (Medical Assistance Facility): "A therapeutic diet for a patient must be prescribed by the practitioner responsible for the care of that patient."

37.106.2171(4) (Developmentally Disabled): "The client's interdisciplinary team, including a qualified dietitian and physician, must prescribe all modified and special diets including those used as a part of a treatment to manage inappropriate client behavior."

37.106.2805(29) (Assisted Living): ''Therapeutic diet' means a diet ordered by a physician or practitioner as part of treatment for a disease or clinical condition or to eliminate or decrease specific nutrients in the diet, (e.g., sodium) or to increase specific nutrients in the diet (e.g., potassium) or to provide food the resident is able to eat (e.g., mechanically altered diet)."

Recommendation:

There is no identified regulation governing therapeutic diets in the hospital setting in Montana (37.106.311 appears to have been repealed). Language for therapeutic diets in other settings differs.

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Nebraska

Status:Yellow

Licensure:

172 NAC 61-00(7)(a)(5) specifies that assessment may include "Recommend[ing] changes in physician's diet order"

172 NAC 61-028 "Medical Nutrition Therapy means the assessment of the nutritional status of patients. It involves the assessment of patient nutritional status followed by treatment, ranging from diet modification to specialized nutrition support, such as determining nutrient needs for enteral and parenteral nutrition, and monitoring to evaluate patient response to such treatment."

Licensure of Medical Nutrition Therapists

Hospital Regulations:

9-006.06C Nutrition: Each hospital must provide for the daily nutritional needs of all patients, including the provision of any diets ordered by a medical practitioner.

9-006.09H Dietary Services: Dietary services must be provided directly or through written agreement to meet the general nutritional needs of patients and must be supervised by a registered dietitian.

Recommendation:

Nebraska does not appear to have any specific limitation as to who can order therapeutic or specialized diets, although the administrative code's reference to "physician's diet order" may need to be expanded to reference qualified medical nutrition therapists privileged by the hospital to order therapeutic diets.

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Nevada

Status: Yellow

Licensure:

NRS 640E.07(1) "'Practice of dietetics' means the performance of any act in the nutrition care process, including, without limitation, assessment, evaluation, diagnosis, counseling, intervention, monitoring and treatment, of a person which requires substantial specialized judgment and skill based on the knowledge, application and integration of the principles derived from the sciences of food, nutrition, management, communication, biology, behavior, physiology and social science to achieve and maintain proper nourishment and care of the health of the person."

640E.260(1) A licensed dietitian shall provide nutrition services to assist a person in achieving and maintaining proper nourishment and care of his or her body, including, without limitation: …

(l) Accepting and transmitting verbal and electronic orders from a physician consistent with an established protocol to implement medical nutrition therapy.

(m) Ordering medical laboratory tests relating to the therapeutic treatment concerning the nutritional needs of a patient when authorized to do so by a written protocol prepared or approved by a physician

2. A licensed dietitian may use medical nutrition therapy to manage, treat or rehabilitate a disease, illness, injury or medical condition of a patient, including, without limitation:

(a) Interpreting data and recommending the nutritional needs of the patient through methods such as diet, feeding tube, intravenous solutions or specialized oral feedings;

(b) Determining the interaction between food and drugs prescribed to the patient; and

(c) Developing and managing operations to provide food, care and treatment programs prescribed by a physician, physician assistant, dentist, advanced practice registered nurse or podiatric physician that monitor or alter the food and nutrient levels of the patient.

Dietitians Licensure Statute

Hospital Regulations:

NAC 449.337(2): "The menu for a patient must meet the nutritional needs of the patient in accordance with: … (b) The orders of the practitioners responsible for the care of the patient."

NAC 449.337 (7): "A hospital shall ensure that persons who are responsible for therapeutic diets have sufficient knowledge of food values to make appropriate substitutions when necessary."

NAC 449.339(7): "If it is determined that the nutritional status of a patient is at risk, nutritional care for that patient must be: (a) Planned and provided based on an assessment of his or her nutritional status by a licensed dietitian or the attending physician, or both; and (b) Integrated into his or her plan of care."

Recommendation:

Nevada's dietetics licensure regulation NAC 449.337(2) needs to be revised to allow qualified licensed dietitians to order therapeutic diets in addition to the "practitioners responsible for the care of the patient." Nevada's hospital regulations appear to have no specific requirement that a physician order the therapeutic diet, merely that the therapeutic diet be in accordance with orders from the practitioners responsible for the care of the patient. This would establish consistency with the licensure statute, which appears to grant licensed dietitians the authority to practice "any act in the nutrition care process … without limitation."

Practice Tips: Order Writing and Privileging

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New Hampshire

Status: Yellow

Licensure:

State licensure statutes and regulations do not specify which practitioners are responsible for ordering therapeutic diets.

326-H:6 "Scope of Practice. – Licensed dietitians shall be authorized to practice applications from food, nutrition, biochemistry, physiology, management, behavioral, and social sciences used in the treatment of illness, injury and other medical conditions, and the maintenance of human health."

Occupations and Professions: Licensed Dietitians

Hospital Regulations:

He-P 802.03(x): "'Dietitian' means a person who is licensed under RSA 326-H."

He-P 802.03(ax): "'Orders' means prescriptions, instructions for administering or discontinuing treatments, special diets or therapies given by a licensed practitioner, or other health professional according to their legally authorized scope of practice."

He-P 802.18(h): "Hospitals shall provide dietary services that include: . . . (2) Diets that are in accordance with the orders of patients' licensed practitioners;"

Recommendation:

Because New Hampshire's includes language stating that diets must be "in accordance with the orders of patients' licensed practitioners," it is important to confirm with the DHHS that this would merely assure consistency between therapeutic diets ordered by RDNs and any superseding order by a physician. New Hampshire allows "other health professional[s] according to their legally authorized scope of practice" to order special diets or therapies.

Practice Tips: Order Writing and Privileging

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New Jersey

Status: Green

Licensure:

None

Hospital Regulations:

§ 8:43G-10.6(c): "A physician shall write a specific dietary order for each patient."

§ 8:43G-10.6(f): "Patients' nutritional needs for food and food supplements shall be met, in accordance with physician orders."

Hospital Licensing Standards

On June 30, 2015, state regulators issued the following document: "…starting immediately as a general waiver, licensed hospitals may allow a physician or an RD to write a specific dietary order for each patient; and patient nutritional needs for food and food supplements shall be met in accordance with physician or RD orders."

Recommendation:

The written waiver should allow RDNs to feel comfortable working with their hospitals to obtain privileges to independently order therapeutic diets. To be technically complete, New Jersey hospital regulations 8.43-10.6(c) should be revised at the next opportunity.

Practice Tips: Order Writing and Privileging

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New Mexico

Status: Yellow

Licensure:

61-7A-3(G) "'nutritional assessment' means the evaluation of the nutritional needs of individuals and groups based upon appropriate biochemical, anthropometric, physical and dietary data to determine nutrient needs and recommend appropriate nutritional intake, including enteral and parenteral nutrition;"

Hospital Regulations:

7.7.2.6 NMAC P.: "'Dietician' means a person who is eligible for registration as a dietitian by the commission on dietetic registration of the American dietetic association, or who has a baccalaureate degree with major studies in food and nutrition, dietetics, or food service management."

7.7.2.28(2): Therapeutic diets shall be prescribed by an authorized individual in written orders on the medical record.

7.7.2.28(3): Nutritional needs shall be in accordance with physicians' orders and, to the extent medically possible, in accordance with the "recommended daily dietary allowance" of the food and nutrition board of the national research council, national academy of sciences. A current edition of these standards shall be available in the dietary service.

Recommendation:

Because New Mexico's rules include language stating that diets must be "in accordance with the orders of patients' licensed practitioners," it is important to confirm with state regulators that this would merely assure consistency between therapeutic diets ordered by RDNs and any superseding order by a physician. New Mexico allows "authorized individuals" to order therapeutic diets. The "in accordance with" language combined with the broad "authorized individual" (as opposed to physician/practitioner responsible for the care of the patient) language suggests those two requirements are separate.

Practice Tips: Order Writing and Privileging

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New York

Status: Yellow

Licensure:

Education content requirements include Section 52.2(a)(1)(v) "food service management, including but not limited to such topics as human resources, planning, purchasing, preparation and service, delivery, and sanitation; (vi) diet modifications;"

Hospital Regulations:

405.23(a)(2): "Nutritional needs of patients shall be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the patients."

405.23(c): Diets. There shall be a systematic record of diets and menus, consistent with the physician's orders which meet the needs of the patients.

405.23(c)(1): "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients."

Recommendation:

Requires updating of 405.23(c) "There shall be a systematic record of diets and menus, consistent with the orders of the physician or qualified dietitian which meet the needs of the patients."

Requires updating of 405.23(c)(1) "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients or qualified dietitian privileged to do so."

Practice Tips: Order Writing and Privileging

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North Carolina

Status: Green

Licensure:

As of July 1, 2018, North Carolina licenses both dietitians/nutritionists (LDN) and nutritionists (LN). Although LDNs and LNs have different requirements in order to achieve licensure, they have the same scope of practice limited by their personal training and competence. Per 10A NCAC 13B.3001 of the NC administrative code, which addresses the licensing of hospitals, a "dietitian" is an individual who is licensed according to the NC Dietetics/Nutrition Practice Act, or is a registered by the Commission on Dietetic Registration.

Recently, the NC Dietetics/Nutrition Practice Act was amended to provide for therapeutic diet order writing and the ordering of laboratory tests related to the practice of nutrition and dietetics. However, given this statutory change just went into effect July 1, 2018, 21 NCAC 17.0101 still provides that "nutrition assessment" means the evaluation of the nutrition needs of individuals and groups based upon biochemical, anthropometric, physical, and food intake and diet history data to determine nutritional needs and recommend appropriate nutrition intake including enteral and parenteral nutrition.

"§ 90-352 (3a, 4) "Medical nutrition therapy. [is defined as] The provision of nutrition care services [which] means – "Any part or all of the following: …

a. Ordering therapeutic diets."

"§ 90-365.6. (a) Enteral and parenteral nutrition therapy shall consist of enteral feedings or specialized intravenous solutions and shall only be ordered by an individual licensed under this Article who meets one of the following criteria:

(1) The individual is a Registered Dietitian Nutritionist registered with the Commission on Dietetic Registration.

(2) The individual is a Certified Nutrition Support Clinician certified by the National Board of Nutrition Support Certification.

(3) The individual meets the requirements set forth in rules adopted by the Board."

Hospital Regulations:

10 NCAC 13B .3001(23): "'Medical staff' means the formal organization that is comprised of all of those individuals who have sought and obtained clinical privileges in a facility. Those members of the medical staff who regularly and routinely admit patients to a facility constitute the active medical staff."

Section .3700 – "Medical Staff" of the regulations addresses the licensing of hospitals provides for the process of being granted clinical privileges."

10A NCAC 13B .4705(c) "Therapeutic diets and enteral and parenteral nutrition therapy shall be prescribed in written orders on the medical records and provided as ordered."

10A NCAC 13B .4705(e) "The qualified dietitian shall be responsible for the development of a nutritional care plan in compliance with medical staff's orders to meet the nutritional needs of the patient."

Recommendation:

Dietitians have clear statutory authority to seek therapeutic diet order writing privileges in NC although dietitians may be limited by a facility's medical staff by-laws, rules, or regulations defining who may be granted clinical privileges.

Practice Tips: Order Writing and Privileging

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North Dakota

Status: Green

Licensure:

North Dakota has different scopes of practice for dietitians and nutritionists; nutritionists in North Dakota practice "general nutrition services" rather than dietetics. Nutrition care services definition at 43-44-01(8)(c) includes "Providing nutrition counseling to meet both normal and therapeutic needs."

Hospital Regulations:

33-07-01.1-19(1)(h): "Regular and therapeutic diets must be prescribed in writing by the licensed health care practitioner. Regular and therapeutic menus must be planned in writing and served as ordered, with supervision or consultation from the dietitian."

Recommendation:

There do not appear to be any statutory or regulatory impediments to qualified dietitians seeking to obtain privileges to order therapeutic diets in North Dakota.

Practice Tips: Order Writing and Privileging

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Ohio

Status: Green

Licensure:

Chapter 4759.01(A)(1) "[the practice of dietetics and nutrition includes "Nutritional assessment to determine nutritional needs and to recommend appropriate nutritional intake, including enteral and parenteral nutrition."

Hospital Regulations:

Do not appear to have any regulations related to dietary department of hospitals.

Special Restriction: Until a disagreement regarding ordering of parenteral nutrition is resolved with the OH Board of Pharmacy, hospitals (including teaching hospitals) have declined to grant privileges to RDNs to order PN.

Recommendation:

With the exception of parenteral nutrition, there do not appear to be any statutory or regulatory impediments to qualified dietitians seeking to obtain privileges to order therapeutic diets in Ohio.

Practice Tips: Order Writing and Privileging

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Oklahoma

Status: Yellow

Licensure:

Title 59 O.S., Section 1722(3): "Dietetics" means the integration and application of principles derived from the sciences of nutrition, biochemistry, food, physiology, behavioral and social sciences to provide nutrition services that include:
a. nutrition assessment,
b. the establishment of priorities, goals and objectives that meet nutritional needs,
c. the provisions of nutrition counseling in health and disease,
d. the development, implementation and management of nutrition care plans, and
e. the evaluation and maintenance of appropriate standards of quality in food and nutrition."

Registered Dietitian Act

435:35-1-4(b)(8): "Developing and implementing plans of nutritional care for individuals, both enteral and parenteral, based on assessment of nutritional needs."
"(11) Participating with physicians and allied health personnel as the provider of nutritional care…"

Oklahoma Administrative Code

Hospital Regulations:

310:667-17-1. Organization (a)(1): "The licensed/registered dietitian shall be responsible for approval of menus, including modified diets. . ."

310:667-17-3(a): ""… Menus shall be planned and followed to meet nutritional needs of patients, in accordance with physicians' or licensed independent practitioners' orders and to the extent medically possible, in accordance with the Dietary Reference Intakes (DRIs)…"

310:667-17-3(b): "Diets shall be prescribed by the physician or licensed independent practitioner responsible for the care of the patient. All modified diets shall be prescribed by the patient's physician or licensed independent practitioner according to the latest edition of the Oklahoma Diet Manual or other equivalent approved diet manual."

Recommendation:

Given that the licensure statute defines "dietetics" to include "implementation" of care plans, and the regulation reinforces that and includes RDNs as "providers," we see a conflict with hospital regulation 310:667-17-3. To enable RDNs in Oklahoma to order therapeutic diets, 310:667-17-3(a) should be revised to the effect of "Menus shall be … in accordance with orders of a physician, a licensed independent practitioner or qualified dietitian privileged by the hospital." In addition, 310:667-17-3(b) should be revised to the effect of: "Diets shall be prescribed by the physician or licensed independent practitioner responsible for the care of the patient or by a qualified dietitian privileged by the hospital to do so. All modified diets shall be prescribed by the patient's physician or licensed independent practitioner or by a qualified dietitian privileged by the hospital to do so according to the latest edition of the Oklahoma Diet Manual or other equivalent approved diet manual."

Practice Tips: Order Writing and Privileging

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Oregon

Status: Green

Licensure:

None

Hospital Regulations:

333-510-0010: "The admitting physician, physician assistant or nurse practitioner shall provide sufficient information at the time of admission … Other pertinent medical information, orders for medication, diet, and treatments shall also be provided…"

333-520-0020(2): "A hospital shall: (b) Employ supportive personnel competent to carry out the functions of the dietary service, including a full-time director with overall supervisory responsibility for the dietary service and who is: (A) A qualified dietitian who is registered by the Commission on Dietetic Registration of the American Dietetic Association;"

333-520-0020(2)(e): "Provide dietetic services to patients in accordance with a written order by the responsible physician, or other health care practitioner authorized within the scope of his or her professional license, and record appropriate dietetic information in the patient's medical record including the following:. . . "

Recommendation:

There is no definitive preclusion of RDN's ability to order therapeutic diets, and they could be considered a "health care practitioner authorized within the scope of his or her professional license."

Practice Tips: Order Writing and Privileging

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Pennsylvania

Status: Green

Licensure:

§ 212 (10) "'Medical nutrition therapy' means the component of nutrition therapy that concerns determining and recommending nutrient needs based on nutritional assessment and medical problems relative to diets prescribed by a licensed physician, including: (i) tube feedings; (ii) specialized intravenous solutions; (iii) specialized oral solutions"

Hospital Regulations:

§ 101.4: "Practitioner—A licensed physician, dentist, or podiatrist."

§ 107.61. "Written orders. Medication or treatment shall be administered only upon written and signed orders of a practitioner acting within the scope of his license and qualified according to medical staff bylaws…"

§111.27(c) "Therapeutic diets, when appropriate, shall be prescribed in written orders on the medical record by the physician and shall be instructive, accurate and as complete as possible."

Recommendation:

Per PA DOH, hospitals are eligible to request an "exception" to 28 Pa. Code § 107.61 relating to Written Orders. Requires approval by PA DOH exception request committee.

Once the PA DOH has issued an exception, a physician member must first order the patient's diet. The physician must then delegate dietary orders to a registered dietician who can under this delegation alter, modify, or change the physician's original order. The physician shall specifically note in the medical record the delegation to the dietician to alter/modify/change the original order.

Contact the Pennsylvania Academy of Nutrition and Dietetics – members of their Public Policy Panel for latest update.

Practice Tips: Order Writing and Privileging

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Rhode Island

Status: Red

Licensure:

None

Hospital Regulations:

4.6.5 (A): "Each facility shall maintain a dietary service directed by a full-time person qualified by training and experience in organization and administration of food service."

4.6.5 (B): "Each hospital shall have at least one Registered Dietitian, licensed by the state, to direct nutritional aspects of patient care and to advise on food preparation and service."

4.6.5 (J): "All patient diets shall be ordered in writing by the physician."

Recommendation:

To enable qualified RDNs to independently order therapeutic diets, it appears that Rhode Island hospital regulation subsection 22.10 will need to be revised to the effect of "All patient diets shall be ordered in writing by the physician or qualified dietitian privileged by the hospital to do so."

Practice Tips: Order Writing and Privileging

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South Carolina

Status: Green

Licensure:

Section 40-20-20(3): "Nutrition services includes "(g) implementing nutrition related orders under a protocol approved by the medical staff of a licensed health care facility."

Hospital Regulations:

Section 1505: "Diets shall be prepared in conformance with orders of a physician or, if permitted by the facility's policies, a dietitian. … A. Diets shall be prescribed, dated and signed or authenticated by the physician or dietitian."

Recommendation:

South Carolina does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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South Dakota

Status: Green

Licensure:

South Dakota differently licenses dietitians and nutritionists, relevant to the question of what qualifications hospitals will require when privileging practitioners to order therapeutic diets.

Hospital Regulations:

44:75:01:01 (15) "'Dietitian,' a person who is registered with the Academy of Nutrition and Dietetics and holds a current license to practice in South Dakota pursuant to SDCL chapter 36-10B;"
(43) 'Qualified personnel,' a person with the specific education or training to provide the health service for which they are employed;
(55) 'Therapeutic diet,' any diet other than a regular diet that is ordered by a physician, physician assistant, nurse practitioner, clinical nurse specialist, or qualified dietitian as part of the treatment for a disease or clinical condition to increase, decrease, or to eliminate certain substances in the diet, and to alter food consistency;
44:75:07:06. Therapeutic diets. In each facility the dietetic service shall provide for the needs of those patients requiring therapeutic diets."

Recommendation:

South Dakota does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Tennessee

Status: Green

Licensure:

63-25-105: "Development of therapeutic dietary regimens. No therapeutic dietary regimen may be developed unless pursuant to the appropriate orders and/or referral of licensed practitioners of medicine, osteopathy, chiropractic, dentistry or podiatry when incidental to the practice of their respective professions."

Hospital Regulations:

Rule 1200-8-1-.01(24): "Dietitian. As used in the chapter, the term 'dietitian' means: (a) A person who is currently licensed by the Tennessee Board of Dietitian/Nutritionist Examiners as a dietitian/nutritionist; or (b) An employee of a Tennessee hospital who is exempt from Tennessee licensure pursuant to T.C.A. § 63-25-104(b)(6) but holds the credential of Registered Dietitian (RD) or Registered Dietitian Nutritionist (RON) from the Commission on Dietetic Registration."

Rule 1200-8-1-.06(9)(c): "…Medical nutrition therapy includes assessment of the nutritional status of the patient and treatment through diet therapy, counseling and/or use of specialized nutrition supplements."

Rule 1200-08-01-.06 Basic Hospital Functions (9)(e)2: "All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian to whom the physician who chairs the hospital's medical executive committee has referred this task. The medical staff and hospital's board of trustees shall decide the extent of ordering privileges that a qualified dietitian shall have and a mechanism to ensure that order writing by a qualified dietitian is coordinated with the responsible practitioner's care of the patient and complies with Tennessee law governing dietitians.""

Recommendation:

As of October 8, 2018, Tennessee will appear to not have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets. Until then, contact your facility or the Tennessee Board of Dietitians/Nutritionist Examiners.

Note the above link for Standards for Hospitals will likely show the original, not updated, language at least until October 8, 2018.

Practice Tips: Order Writing and Privileging

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Texas

Status: Green

Licensure:

116.2(11): "Dietetics--… The term includes, without limitation, the development, management, and provision of nutrition services."

116.2 (16): "Nutrition assessment--The evaluation of the nutritional needs of individuals and groups based on appropriate biochemical, anthropometric, physical, and dietary data to determine nutrient needs and recommend appropriate nutritional intake including enteral and parenteral nutrition. An important component of medical nutrition therapy."

116.141(b): "A licensed dietitian, acting within the scope of his or her license and consistent with medical direction or authorization as provided in this section, may accept, transcribe into a patient's medical record or transmit verbal or electronically-transmitted orders, including medication orders, from a physician to other authorized health care professionals relating to the implementation or provision of medical nutrition therapy and related medical protocols for an individual patient or group of patients. (1) In a licensed health facility, the medical direction or authorization shall be provided, as appropriate, through a physician's order, or a standing medical order, or standing delegation order, or medical protocol issued in accordance with Texas Occupations Code, Chapter 157, Subchapter A, and rules adopted by the Board of Medical Examiners implementing the subchapter..."

Hospital Regulations:

Rule §133.2(15): ""Dietitian--A person who is currently licensed by the Texas State Board of Examiners of Dietitians as a licensed dietitian or provisional licensed dietitian, or who is a registered dietitian with the American Dietetic Association."

Rule §133.41(1)(d)(B): ""… The dietitian shall: (i) be currently licensed under the laws of this state to use the titles of licensed dietitian or provisional licensed dietitian, or be a registered dietitian; . . . (iii) supervise the nutritional aspects of patient care; (iv) make an assessment of the nutritional status and adequacy of nutritional regimen, as appropriate; . . . (vi) document nutritional status and pertinent information in patient medical records, as appropriate;"

Rule §133.41(3)(A): "Therapeutic diets shall be prescribed by the physician(s) responsible for the care of the patients."

Rule §133.41(3)(B): "Nutritional needs shall be met in accordance with recognized dietary practices and in accordance with orders of the physician(s) or appropriately credentialed practitioner(s) responsible for the care of the patients."

State Guidance Letter: "…effective [April 15, 2016], the department is allowing hospital discretion and flexibility in determining whether to adopt, implement, and enforce policies and procedures that will allow qualified dieticians, as defined at 25 Texas Administrative Code (TAC) §133.41(d)(1)(B), to order therapeutic diets when authorized by medical staff and in accordance with state law governing dietitians and nutrition professionals."

Recommendation:

Pursuant to a state guidance letter, it appears that Texas regulators are permitting RDNs to order therapeutic diets in the hospital setting if privileged by their hospital staffs to do so.

Practice Tips: Order Writing and Privileging

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Utah

Status: Green

Licensure:

None

Hospital Regulations:

R432-100-31(3)(a): "The food and nutritional needs of patients, including therapeutic diets, shall be met in accordance with the orders of the physician responsible for the care of the patient, or if delegated by the physician, the orders of a qualified registered dietitian in consultation with the physician, as authorized by the medical staff and in accordance with facility policy."

Recommendation:

Utah does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets if authority is delegated by the physician.

Practice Tips: Order Writing and Privileging

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Vermont

Status: Green

Licensure:

None

Hospital Regulations:

None

Recommendation:

There does not appear to be any regulatory or statutory impediment to qualified RDNs in Vermont seeking privileges to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Virginia

Status: Green

Licensure:

None

Hospital Regulations:

12 VAC 5-410-260(B): "Each hospital shall have at least one dietitian, meeting the criteria of §54.1-2731 of the Code of Virginia"

12 VAC 5-410-260(F): "All patient diets, including therapeutic diets, shall be ordered in writing by a practitioner, or by a dietitian as authorized by the medical staff, responsible for the care of the patient.

  1. Hospitals and their medical staffs may grant privileges to dietitians meeting the criteria of § 54.1-2731 of the Code of Virginia to order patient diets, including therapeutic diets, and to order laboratory tests to help determine appropriate diets for the patient.
  2. Therapeutic diets include the provision of enteral and parenteral nutrition.

Recommendation:

Virginia does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Washington

Status: Green

Licensure:

None

Hospital Regulations:

246-320-010 (6) "Authentication" means the process used to verify an entry is complete, accurate, and final.

246-320-010(12): "'Dietitian' means an individual meeting the eligibility requirements for active membership in the American Dietetic Association described in Directory of Dietetic Programs Accredited and Approved, American Dietetic Association, edition 100, 1980."

246-320-010 (25) "Governing authority/body" means the person or persons responsible for establishing the purposes and policies of the hospital.

246-320-131: "For the purposes of this section "practitioner" means pharmacists as defined in chapter 18.64 RCW; advanced registered nurse practitioners as defined in chapter 18.79 RCW; dentists as defined in chapter 18.32 RCW; naturopaths as defined in chapter 18.36A RCW; optometrists as defined in chapter 18.53 RCW; osteopathic physicians and surgeons as defined in chapter 18.57 RCW; osteopathic physicians' assistants as defined in chapter 18.57A RCW; physicians as defined in chapter 18.71 RCW; physician assistants as defined in chapter 18.71A RCW; podiatric physicians and surgeons as defined in chapter 18.22 RCW; and psychologists as defined in chapter 18.83 RCW.

The governing authority must: (1) Establish and review governing authority policies including requirements for: …(g) Defining who can give and receive patient care orders that are consistent with professional licensing laws; …(4) Require written or electronic orders, authenticated by a legally authorized practitioner, for all drugs, intravenous solutions, blood, medical treatments, and nutrition…"

246-320-201: "(2) Designate a registered dietitian responsible to develop and implement policies and procedures addressing nutritional care for patients; (3) Have a registered dietitian available to assess nutritional needs, based on patients' individual nutritional risk screen;"

Recommendation:

Washington does not appear to have any regulations precluding RDNs in hospitals from becoming privileged to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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West Virginia

Status: Yellow

Licensure:

None

Hospital Regulations:

64-12-7.3.e: "… Only a qualified dietician or other person with suitable training may direct the food services department."

64-12-7.3.g. "There shall be a qualified dietician available on a full-time, part-time, or a consultant basis. A qualified dietician shall be registered or eligible for registration with the Commission on Dietetic Registration of the American Dietetic Association and be licensed in the State of West Virginia by the Board of Licensed Dietitians."

64-12-7.3.k: "All therapeutic diets, including between meal nourishments, shall be prepared and served as prescribed by the attending practitioner."

Recommendation:

Unless an RDN is deemed the attending practitioner, West Virginia regulation 64-12-7.3k will need to be changed to something similar to "All therapeutic diets, including between meal nourishments, shall be prepared and served as prescribed by the attending practitioner or qualified dietitian privileged by the hospital to do so."

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Wisconsin

Status: Green

Licensure:

None

Hospital Regulations:

None (previous hospital regulation DHS 124.16(5)(b) was repealed by 2013 Wisconsin Act 236 Section 5.)

Recommendation:

Wisconsin does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

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Wyoming

Status: Green

Licensure:

33-47-102(a)(vi): "'Medically prescribed diet' means a diet prescribed when specific food or nutrient levels need to be monitored, altered, or both, as a component of a treatment program from an individual whose health status is impaired or at risk due to disease, injury or surgery and may only be performed as initiated by or in consultation with a physician licensed in this state or an individual authorized by a state license to prescribe medical care;"

Ch. 7, Section 2. Scope of Practice …
(b) Licensees may order patient diets.
(c) Licensees may order lab tests to check and track nutrition status and monitor effectiveness of dietary plans and orders.

Hospital Regulations:

Chapter 12, Section 17(j): "'Dietitian' means a person who is registered by the Commission on Dietetic Registration and provides nutritional and dietary services."

Recommendation:

Wyoming does not appear to have any regulations precluding RDNs in hospitals from becoming privileged to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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