Clinical Dietitians: Do You Have Order Writing Privileges in Your Hospital?

In 2014, Centers for Medicare and Medicaid Services (CMS) ruled that physicians can delegate the responsibility of writing therapeutic diet orders to a qualified RDNs. Now this doesn’t mean that every dietitian automatically can order patient diets. First, the privileging of RDNs must also meet state law and fall within scope of practice defined by the state in which the RDN is practicing. State legislature often reflects the regulations imposed by CMS, so legislation may have to change before certain state are able to implement the new changes CMS has declared. Second, the RDN must request the privileges from the hospital or facility they are practicing at. The hospital has the abuthority to assess the practitioner and determine if they are qualified and competent to obtain order writing privileges.

What does it mean to have order writing privileges? RDNs who have order writing privileges can order or change therapeutic diets for patients either on their own or with a co-signature from a physician. The CMS rule may also allow RDNs to order or change oral nutrition supplements, modify diet texture, order or change nutrition support such as enteral or parenteral nutrition, and order nutrition-related laboratory tests. Other specific privileges may also be granted depending on the competence and scope of practice of the RDN. For example, because of Ohio law, RDNs can change parenteral diet orders once ordered by a physician but cannot initiate them.

CMS recognized that delegating these responsibilities to a qualified RDN can result in significant advantages for the facility in terms of cost-savings. And when it comes down to the bottom line, that is one of the major factors considered when facilities make a major change in policy and procedure. Other research from facilities that have implemented this process have found positive results in patient care including reduction in error rates of diet orders, reduction in time delays of diet order, decreases in both direct and indirect costs, and improved patient outcomes, particularly for those receiving nutrition support.

The scope of practice and standards of professional practice for RDNs both support the qualification of RDNs for this role in the interdisciplinary healthcare team. If your hospital does not have order writing privileges, it may be time to assess your facility and examine your options for obtaining these responsibilities. The Academy of Nutrition and Dietetics also has tools and resources available to guide your way.

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Academy of Nutrition and Dietetics (n.d.). CMS rules on therapeutic diet orders. Retrieved from:https://www.eatrightpro.org/advocacy/licensure/therapeutic-diet-orders#q7.

Academy of Nutrition and Dietetics (2018). Practice tips: Implementation steps – ordering privileges for the RDN. Retrieved from: https://www.eatrightpro.org/-/media/eatrightpro-files/advocacy/practicetipsimplementationstepsorderingprivilegesfortherdn.pdf?la=en&hash=D5EA65A10486EA214BC471B51B57436318DEC036.

Andersen, D., Baird, S., Bates, T., Chapel, D. L., Cline, A. D., Ganesh, S. N., ... & Jones, S. L. (2018). Academy of Nutrition and Dietetics: Revised 2017 scope of practice for the registered dietitian nutritionist. Journal of the Academy of Nutrition and Dietetics, 118(1), 141-165.

Andersen, D., Baird, S., Bates, T., Chapel, D. L., Cline, A. D., Ganesh, S. N., ... & Jones, S. L. (2018). Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in nutrition care and Standards of Professional Performance for registered dietitian nutritionists. Journal of the Academy of Nutrition and Dietetics, 118(1), 132-140.

Duffy, J., Gray, R. L., Roberts, S., & Cheng, M. (2007). Independent nutrition order writing by registered dietitians improves patient outcomes. Journal of the American Dietetic Association, 107(8), A86.

Imfeld, K., Keith, M., Stoyanoff, L., Fletcher, H., Miles, S., & McLaughlin, J. (2012). Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals. Journal of the Academy of Nutrition and Dietetics, 112(10), 1656-1661.

Peterson, S. J., Chen, Y., Sullivan, C. A., Kinnare, K. F., Tupesis, N. C., Patel, G. P., ... & Sheean, P. M. (2010). Assessing the influence of registered dietitian order-writing privileges on parenteral nutrition use. Journal of the American Dietetic Association, 110(11), 1703-1711.

Phillips, W. & Doley, J. (2016). Granting order-writing privileges to Registered Dietitian Nutritionists can decrease costs in acute care hospitals. Journal of the Academy of Nutrition and Dietetics, 117(6), 840-847.