Diet Orders

Over the past few years the NCBDN has received an increasing number of inquiries regarding the ability of licensees to write parenteral nutrition orders. The writing of diet/nutrition orders is not specifically addressed within the Dietetics Practice Act. Rather, what the law does provide is a broad scope of practice defined as nutrition care services. Under North Carolina General Statute § 90-352 nutrition care services are defined as follows: “[n]utrition care services” means any, part or all of the following:

  • Assessing the nutritional needs of individuals and groups, and determining resources and constraints in the practice setting.
  • Establishing priorities, goals, and objectives that meet nutritional needs and are consistent with available resources and constraints.
  • Providing nutrition counseling in health and disease.
  • Developing, implementing, and managing nutrition care systems.
  • Evaluating, making changes in, and maintaining appropriate standards of quality in food and nutrition services.

Nutrition assessment, as defined in the corresponding regulations under 21 NCAC 17.0101(11), addresses recommending “appropriate nutrition intake including enteral and parenteral nutrition,” but no further guidance regarding writing orders is provided in the administrative code. Given the lack of clear authority, as more dietitians/nutritionists are asked and/or are seeking to write such orders, questions regarding what the NCBDN would advise have also increased.

The NCBDN recognizes that the current practice in many hospitals across the state is to allow for dietitians/nutritionists to write parenteral nutrition orders when it is done under a defined protocol, initiated by written order from a physician, and signed off on by a physician within a reasonable time before or after the bag is hung. Recent guidance from the NC Medical Board’s legal counsel indicated that they would find such practices in line with the current standard of care in North Carolina, and not in violation of the practice of medicine.

Appreciating this guidance, but also noting the lack of clear legal authority within the Dietetics Practice Act specifically addressing order writing, the NCBDN would advise that as a licensee you ensure that if you are asked to write parenteral nutrition orders in a hospital setting, you are competent to do so, writing such orders is addressed within a clear protocol or policy adopted by the physicians at your facility, that a physician initiates the order in writing, and that the order is signed off on by a physician within a reasonable timeframe either before or after the bag is hung.

Ultimately, eventual clarity within the statute addressing dietitians/nutritionists’ scope of practice regarding order writing should be addressed. But, until such clarity can be achieved, adhering to the guidance provided above will help ensure all NC citizens requiring parenteral nutrition are provided safe, timely, nutrition interventions.

It is important to keep in mind that all licensees of the NCBDN are expected to abide by the Code of Ethics for Professional Practice and Conduct as outlined in 21 NCAC 17.0114. This includes, but is not limited to, assuming responsibility and accountability for personal competence in practice and recognizing and exercising professional judgment within the limits of the licensee’s qualifications and not accepting or performing professional responsibilities which the licensee knows or has reason to know that he or she is not qualified to perform.

Helpful AND documentation regarding the 2014 CMS order writing regulation changes is found below:

Practice Tips – AND Standards of Practice Document

Practice Tips – RDs and Hospital Privileges 2015

Practice Tips – RDs and Nutrition (Diet) Order Writing 2015