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Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Nutrition and Dietetics Technicians, Registered

Published:December 24, 2017DOI:https://doi.org/10.1016/j.jand.2017.10.004

      Abstract

      Nutrition and dietetics technicians, registered (NDTRs) face complex situations every day. Competently addressing the unique needs of each situation and applying standards appropriately are essential to providing safe, timely patient-/client-/customer-centered quality nutrition and dietetics care and services. The Academy of Nutrition and Dietetics (Academy) leads the profession by developing standards that can be used by NDTRs (who are credentialed by the Commission on Dietetic Registration) for self-evaluation to assess quality of practice and performance. The Standards of Practice reflect the NDTR’s role under the supervision of registered dietitian nutritionists in nutrition screening and the Nutrition Care Process and workflow elements, which includes nutrition screening, nutrition assessment, nutrition diagnosis, nutrition intervention/plan of care, nutrition monitoring and evaluation, and discharge planning and transitions of care. The Standards of Professional Performance consist of six domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, indicators provide measurable action statements that illustrate how the standard can be applied to practice. The Academy’s Revised 2017 Standards of Practice and Standards of Professional Performance for NDTRs along with the Academy/Commission on Dietetic Registration Code of Ethics, and the Scope of Practice for the NDTR provide minimum standards and tools for demonstrating competence and safe practice, and are used collectively to gauge and guide an NDTR’s performance in nutrition and dietetics practice.
      Approved September 2017 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the House of Delegates Leadership Team on behalf of the House of Delegates. Scheduled review date: June 2023. Questions regarding the Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Nutrition and Dietetics Technicians, Registered, may be addressed to the Academy Quality Management Staff: Dana Buelsing, manager, Quality Standards Operations; and Sharon M. McCauley, MS, MBA, RD, LDN, FADA, FAND, senior director, Quality Management at [email protected].
      Editor’s note: Figures 2 and 3 that accompany this article are available online at www.jandonline.org.
      The Academy of Nutrition and Dietetics (Academy) leads the profession of nutrition and dietetics by developing standards against which the quality of practice and performance of Nutrition and Dietetics Technicians, Registered (NDTRs) can be evaluated. The following Academy foundational documents guide the practice and performance of NDTRs in all practice settings: Revised 2017 Standards of Practice (SOP) in Nutrition Care and Standards of Professional Performance (SOPP) for NDTRs, along with the Academy/Commission on Dietetic Registration (CDR) Code of Ethics (Revised and approved Code of Ethics available in 2018)
      American Dietetic Association/Commission on Dietetic Registration
      Code of Ethics for the Profession of Dietetics and process for consideration of ethical issues.
      and the Revised 2017 Scope of Practice for the NDTR.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered.
      NDTRs are nutrition and dietetics practitioners credentialed by CDR who are specifically trained and qualified to provide nutrition and dietetics services, and are accountable and responsible for their competent practice. The Standards of Practice (SOP) in Nutrition Care and Standards of Professional Performance (SOPP) define minimum competent level of practice for NDTRs.
      The Academy’s Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Dietetic Technician, Registered (DTR) may optionally use “Nutrition and Dietetics Technician, Registered” (NDTR). The two credentials have identical meanings. The same determination and option also applies to those who hold the credential Registered Dietitian (RD) and Registered Dietitian Nutritionist (RDN). The two credentials have identical meanings. In this document, the term NDTR is used to refer to both dietetic technicians, registered and nutrition and dietetics technicians, registered, and the term RDN is used to refer to both registered dietitians and registered dietitian nutritionists.

      Client/Patient/Resident/Family/Customer

      Generally, these terms are used interchangeably with the specific term used in a given situation, dependent on the setting and the population receiving care or services. Examples of terms used include, but are not limited to: patient/client, patient/client/customer, resident, participant, student, consumer, or any individual/person, group, population, or organization to which the NDTR provides service. In a clinical setting, the term patient/client is commonly used. As a universal term, the use of customer in the Standards of Professional Performance is intended to encompass all of the other terms with the meaning taken by the reader reflecting the context of the situation and setting. Use of customer is not intended to imply monetary exchange.

      What Are the SOP and SOPP for NDTRs?

      The standards and indicators found within the SOP and SOPP reflect the minimum competent level of nutrition and dietetics practice and professional performance for NDTRs. The SOP in Nutrition Care is composed of four standards that apply the Nutrition Care Process and Terminology in the care of patients/clients/populations (see Figure 1).
      • Swan W.I.
      • Vivanti A.
      • Hakel-Smith N.A.
      • et al.
      Nutrition Care Process and Model update: Toward realizing people-centered care and outcomes management.
      The SOPP for NDTRs consist of standards representing six domains of professional performance (see Figure 1).
      Figure 1What are the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Nutrition and Dietetics Technicians, Registered (NDTRs)?
      The SOP in Nutrition Care:
      • incorporates the Nutrition Care Process and workflow elements as a method to manage nutrition care activities (ie, nutrition screening, nutrition assessment, nutrition diagnosis, nutrition intervention/plan of care, nutrition monitoring and evaluation, and discharge planning and transitions of care);
      • applies to NDTRs who provide nutrition care to patients/clients/populations in acute and post-acute health care, ambulatory care, home-based, public health and community settings; and
      • describes the relationship of the NDTR to the registered dietitian nutritionist (RDN) to illustrate the work of the RDN/NDTR team providing patient/client/population care and the circumstances under which the NDTR works under the supervision of the RDN.
      The SOPP:
      • are formatted according to six domains of professional performance (ie, Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources);
      • apply to all NDTRs maintaining the NDTR credential:
        • in all practice settings; and
        • not practicing in nutrition and dietetics.
      The SOP and SOPP reflect the education, training, responsibility, and accountability of the NDTR. Both sets of standards and indicators (Figures 2 and 3, available at www.jandonline.org) comprehensively describe the minimum expectation for competent care of the patient/client/customer, delivery of services, and technical practice outcomes for the NDTR. This article represents the 2017 update of the Academy’s SOP in Nutrition Care and SOPP for NDTRs.

      Why Are the Standards Important for NDTRs?

      The standards promote:
      • safe, effective, quality, and efficient food, nutrition, and related services, and dietetics practice;
      • evidence-based practice and best practices;
      • improved nutrition and health-related outcomes and cost-reduction methods;
      • efficient management of time, finances, supplies, technology, and natural and human resources;
      • quality assurance, performance improvement, and outcomes reporting;
      • ethical and transparent business, billing, and financial management practices
        • Hodorowicz M.A.
        • White J.V.
        Ethics in action: Elements of ethical billing for nutrition professionals.
        • Grandgenett R.
        • Derelian D.
        Ethics in action: Ethics in business practice.
        ;
      • verification of practitioner qualifications and competence because state and federal regulatory agencies, such as health departments and the Centers for Medicare and Medicaid Services (CMS) look to professional organizations to create and maintain standards of practice

        US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 151, 11-20-15); §482.28 Food and Dietetic Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed December 1, 2017

        US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Transmittal 169−Advance Copy State Operations Manual. Appendix PP-Guidance to surveyors for long-term care facilities. Issued June 30, 2017 (updates current Appendix PP Rev. 168, with Phase 2 revisions effective 11-28-17); §483.60 Food and Nutrition Services. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf. Accessed December 1, 2017.

        ;
      • practitioner competence and adherence to the rules and regulations of state departments of health and federal regulatory agencies, such as CMS, which state that technical personnel demonstrate competence through education, experience, and specialized training with appropriate credentials as required to perform task(s) assigned

        US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 151, 11-20-15); §482.28 Food and Dietetic Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed December 1, 2017

        US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Transmittal 169−Advance Copy State Operations Manual. Appendix PP-Guidance to surveyors for long-term care facilities. Issued June 30, 2017 (updates current Appendix PP Rev. 168, with Phase 2 revisions effective 11-28-17); §483.60 Food and Nutrition Services. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf. Accessed December 1, 2017.

        ;
      • consistency in practice and performance;
      • nutrition and dietetics research, innovation, and practice development; and
      • individual career advancement.
      The standards provide:
      • minimum competent levels of practice and performance;
      • common measurable indicators for self-evaluation;
      • a foundation for public accountability in nutrition and dietetics care and services;
      • a description of the role of nutrition and dietetics and the unique services that NDTRs offer within the health care team and in practice settings outside of health care;
      • guidance for policies and procedures, job descriptions, competence assessment tools; and
      • academic and supervised practice objectives for education programs.

      How Does the Academy’s Scope of Practice for the NDTR Guide the Practice and Performance of NDTRs in All Settings?

      The Revised 2017 Scope of Practice for the NDTR is composed of statutory, if applicable, and individual components, including the codes of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics), and encompasses the range of roles, activities, and regulations within which NDTRs perform.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered.
      In states where a practice act addresses NDTRs, state licensure acts or certification statutes, as well as other state statutes, and regulations define the NDTR’s statutory scope of practice and may delineate the services the NDTR is authorized to perform in that state. State practice acts for RDNs may address the role and supervision required by the RDN, as the NDTRs may be engaged in patient/client care, nutrition education, and population health. In 2017, 46 states had statutory provisions regarding professional regulations for dietitians and nutritionists; one state had statutory provisions for NDTRs (http://www.eatrightpro.org/resource/advocacy/legislation/all-legislation/licensure).
      The NDTR’s individual scope of practice is determined by education, training, credentialing, experience, and demonstrating and documenting competence to practice. Individual scope of practice in nutrition and dietetics has flexible boundaries to capture the depth and breadth of the individual’s professional practice. The Scope of Practice Decision Tool (www.eatrightpro.org/scope), an online interactive tool, guides an NDTR through a series of questions to determine whether a particular activity is within his or her scope of practice. The tool is designed to allow for an NDTR to critically evaluate his or her personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.

      Why Were the Standards Revised?

      Academy documents are reviewed and revised every 7 years and reflect the Academy’s expanded and enhanced mission and vision of accelerating improvements in global health and well-being through food and nutrition. Regular reviews are indicated to consider changes in health care and other business segments, public health initiatives, new or revised practice guidelines and research, performance measurement, consumer interests, technological advances, and emerging service delivery options and practice environments. Questions and input from credentialed practitioners, federal and state regulations, accreditation standards, and other factors necessitated review and revision of the 2012 “core” SOP in Nutrition Care and SOPP for DTRs to assure safe, quality, and competence in practice.
      Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Dietetic Technicians, Registered.
      The 2012 core SOP in Nutrition Care and SOPP for Registered Dietitians was reviewed/revised and has been published in the Journal.
      Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitians.
      Examples of significant changes impacting the NDTR since the published Revised 2012 SOP in Nutrition Care and SOPP for DTRs include updates in the CMS Department of Health and Human Services Conditions of Participation affecting Long-Term Care in November 2016, the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, and the implementation of national diabetes prevention programs in community settings.

      Long-Term Care

      The Long-Term Care Final Rule published October 4, 2016 in the Federal Register “allows the attending physician to delegate to a qualified dietitian or other clinically qualified nutrition professional the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by State law” and permitted by the facility’s policies.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489 Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. Final Rule (FR DOC#2016; pp68688-68872)−Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178). https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities. Accessed December 1, 2017.

      NDTRs working in skilled or long-term care facilities as the food and nutrition director/manager will be able to work in collaboration with the facility’s RDN to address a resident’s diet- or nutrition-related orders when the physician has delegated diet order writing to the RDN.
      NDTRs who work in long-term care settings should review the Academy’s updates on CMS (www.eatrightpro.org/quality), which outline the regulatory changes to §483.60 Food and Nutrition Services to evaluate, in collaboration with the qualified dietitian or clinically qualified nutrition professional, current practices that may need to be modified (eg, addition of food and nutrition representative to the interdisciplinary team for development of resident care plans).
      Review revisions to the CMS State Operations Manual, Appendix PP-Guidance to Surveyors for Long-Term Care Facilities (includes the changes to §483.60 Food and Nutrition Services).

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Transmittal 169−Advance Copy State Operations Manual. Appendix PP-Guidance to surveyors for long-term care facilities. Issued June 30, 2017 (updates current Appendix PP Rev. 168, with Phase 2 revisions effective 11-28-17); §483.60 Food and Nutrition Services. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf. Accessed December 1, 2017.

      IMPACT Act—Implications for Hospitals and Post-Acute Care Conditions of Participation

      The IMPACT Act of 2014 amends Title XVIII of the Social Security Act by adding a new section—Standardized Post-Acute Care Assessment Data for Quality, Payment, and Discharge Planning. Post-acute care providers include home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals. In addition, the legislation includes new survey and medical review requirements for hospice care. The Act requires submission and reporting of specific standardized assessment and quality measure outcomes data with the overarching intent to reform post-acute care payments and reimbursement, while ensuring continued beneficiary access to the most appropriate setting for care.
      The Act includes quality measure domains that address, at a minimum, functional status, skin integrity, incidence of major falls, hospital readmissions, and the transfer of health information and care preferences when an individual transitions to a different care setting. These quality measure domains provide opportunities for NDTRs and RDNs to help post-acute and long-term health care settings achieve positive clinical outcomes, quality measure improvement, and cost savings, as well as provide an improved quality of life. Obtain IMPACT Act practice resources on the Academy website at www.eatrightpro.org/impact.
      In response to provisions of the IMPACT Act, CMS published a proposed rule in November 2015 (final action to be determined by November 2018; https://www.regulations.gov/docket?D=CMS-2015-0120) to revise the discharge planning requirements for hospitals including long-term care hospitals and inpatient rehabilitation facilities, home health agencies, and critical access hospitals. The provisions address discharge planning policies and procedures, applicable patient types, timing, people involved (includes patient and caregiver), criteria for evaluation of discharge needs, discharge instructions, post-discharge follow-up, transfers (required medical information to the receiving facility), and other hospital requirements (eg, improving focus on behavioral health).

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; revisions to requirements for discharge planning for hospitals, critical access hospitals, and home health agencies. 42 CFR Parts 482, 484, 485 Proposed Rule−Federal Register November 3, 2015. https://www.federalregister.gov/documents/2015/11/03/2015-27840/medicare-and-medicaid-programs-revisions-to-requirements-for-discharge-planning-for-hospitals. Accessed December 1, 2017.

      Check the CMS Regulations and Guidance page regularly, as Hospital Conditions of Participation updates and revisions are released continuously (https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html).

      National Diabetes Prevention Program

      The Centers for Disease Control and Prevention (CDC) developed the National Diabetes Prevention Program−Lifestyle Change Program delivered nationwide by partner CDC-recognized community organizations. The CDC’s goal is to “make it easier for people with prediabetes to participate in affordable, high-quality lifestyle programs to reduce their risk of type 2 diabetes and improve their overall health.”

      Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation. National Diabetes Prevention Program. http://www.cdc.gov/diabetes/prevention/index.html. Accessed December 1, 2017.

      CMS plans to cover a new preventive service in the future, the Medicare Diabetes Prevention Program, which closely aligns with the CDC’s Diabetes Prevention Program.

      Centers for Medicare & Medicaid Services. Medicare Diabetes Prevention Program (MDPP) Expanded Model. https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/index.html. Accessed December 1, 2017.

      These programs are potential opportunities for interested NDTRs to qualify for a position as a “lifestyle coach.” While there are some differences between the two programs in eligibility requirements and service components, the programs share common characteristics, such as using the CDC-approved Diabetes Prevention Program curriculum and facilitation by a lifestyle coach.

      How Were the Standards Revised?

      The members of the Quality Management Committee and its Scope/Standards of Practice Workgroup utilized collective experience and consensus in reviewing and revising statements, where needed, to support safe, quality practice, and desirable outcomes. The review focused on definitions of terms, illustrative figures and tables, consideration of services and activities in current practice, and enhancements to support future practice and advancement. The 2017 standards, rationales, and indicators were updated using information from questions received by the Academy’s Quality Management Department; discussions with the Academy’s Dietetic Practice Groups, Academy’s Standing Committees (eg, Consumer Protection and Licensure Subcommittee, Nutrition Informatics Committee), Accreditation Council for Education in Nutrition and Dietetics, and CDR; and member comments through focus area SOP and SOPP development.

      What Is the Relationship of the NDTR and RDN in Delivering Person-/Client-/Population-Centered Care?

      The RDN is responsible for supervising or providing oversight of any patient/client/population care activities assigned to professional, technical, and support staff, including the NDTR, and can be held accountable to the patients/clients/populations and others for services rendered. The following resources provide additional information regarding the roles and practice of NDTRs: Revised 2017 Scope of Practice for the NDTR,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered.
      the Revised 2017 SOP in Nutrition Care and SOPP for RDNs,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      Practice Tips: The RDN/NDTR Team-Steps to Preserve,

      Academy of Nutrition and Dietetics. Practice tips: The RDN-NDTR team—Steps to preserve. http://www.eatrightstore.org/product/C6E60A2F-BCED-4F3F-BC55-9A99C6BF4002. Accessed December 1, 2017.

      and Practice Tips: What is Meant by “Under the Supervision of the RDN”?

      Academy of Nutrition and Dietetics. Practice tips. What is meant by “under the supervision of the RDN.” http://www.eatrightstore.org/product/9E555AC7-ED41-445E-931C-C951BE0F14B3. Accessed December 1, 2017.

      In direct patient/client/population care, the RDN and NDTR work as a team using a systematic process reflecting the Nutrition Care Process
      • Swan W.I.
      • Vivanti A.
      • Hakel-Smith N.A.
      • et al.
      Nutrition Care Process and Model update: Toward realizing people-centered care and outcomes management.
      and the organization’s manual or electronic documentation system, for example, an electronic health record, that uses one of the available standardized terminologies that may incorporate the electronic Nutrition Care Process Terminology (eNCPT).

      Academy of Nutrition and Dietetics. Practice tips: The RDN-NDTR team—Steps to preserve. http://www.eatrightstore.org/product/C6E60A2F-BCED-4F3F-BC55-9A99C6BF4002. Accessed December 1, 2017.

      Academy of Nutrition and Dietetics Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. https://ncpt.webauthor.com. Accessed December 1, 2017.

      The RDN develops and oversees the system for delivery of nutrition care activities, often with the input of others, including the NDTR. Components of the nutrition care delivery system might include the following: policies and procedures, protocols, standards of care, forms and tools (eg, screening, food preferences, and food intake), documentation standards, and roles and responsibilities of professional, technical, and support personnel participating in the care of patients/clients. The RDN is responsible for completing the nutrition assessment; determining the nutrition diagnosis(es); developing the care plan; implementing the nutrition intervention; evaluating the patient’s/client’s response; and also supervising the activities of professional, technical, and support personnel assisting with the patient’s/client’s care.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      Although NDTRs are not employed in all facilities, when they are available, NDTRs are important members of the care team. The NDTR is often the first staff from the nutrition team that a patient or client meets. The NDTR serves as a conduit of nutrition care information to RDNs and other team members at meetings and care conferences, and contributes to the continuum of care by facilitating communication between nutrition care and nursing staff.
      The RDN assigns duties that are consistent with the NDTR’s individual scope of practice. For example, the NDTR may initiate standard procedures, such as completing and/or following up on nutrition screening for assigned units/patients; performing routine activities based on diet order, and/or policies and procedures; completing the intake process for a new clinic patient/client; and reporting to the RDN when a patient’s/client’s data suggest the need for an RDN evaluation. The NDTR actively participates in nutrition care by contributing information and observations; guiding patient's/client's menu selections, monitoring menu selections, meals/snacks/nutritional supplements for compliance to diet order; and providing nutrition education on prescribed diets. The NDTR reports to the RDN on the patient’s/client’s response, including implementation of intervention, documenting outcomes and providing evidence signifying the need to adjust the nutrition intervention/plan of care.

      What is Meant by “Under the Supervision of an RDN”?

      To comply with laws, regulations, and accreditation standards, the Academy evaluated the requirement for RDN supervision of the NDTR and other professional, technical, and support personnel involved in direct nutrition care of patients/clients.
      The Academy describes supervision of nutrition care delivered to patients/clients/populations as follows:
      • RDNs are accountable for the nutrition care of patients/clients in various health care settings (eg, hospitals, nursing homes, home health agencies, clinics, end-stage renal facilities), public health programs (eg, Special Supplemental Nutrition Program for Women, Infants, and Children), and nutrition services provided by the Older Americans Act (through provision of daily meals provided in congregate and home-delivered settings). NDTRs may be supervised by RDNs in any of these settings in which patient-/client-/population-centered care is provided.
      • In many health care settings, an NDTR and other staff may be available to assist the RDN and implement routine delivery of food and nutrition services to the patient/client/customer. An RDN in these settings may assign activities to the NDTR and other support personnel consistent with the individual’s qualifications and competence. The RDN is responsible for overseeing duties assigned to others and must answer to patients/clients/advocates, employers, regulators, and boards of dietetics licensure if care is compromised.
      • The RDN may assign certain tasks for the purpose of obtaining needed information (eg, screening data, diet history) or communicating with and educating patients/clients/populations. An RDN may assign interventions within the NDTR scope of practice and demonstrated and documented competence, such as nutrition education, monitoring consumption of meals and medical food/nutrition supplements, and referring patients/clients to community agencies and programs. The NDTR and other professional, technical, and support staff can contribute valuable information and observations to the RDN that supports quality patient-/client-/population-centered care.
      • Whether the supervision is direct (RDN is on premises and immediately available) or indirect (RDN is immediately available by telephone or other electronic means) is determined by regulations and the organization’s policies and procedures.
      • Additional considerations include regulations, state dietitian/nutritionist licensure statutes, and rules that may include definitions of supervision and scope of practice specifications for professional, technical, and other support staff. Federal and state rules and regulations for health care facilities, dialysis centers, and food and nutrition assistance programs specify the responsibilities for the qualified dietitian.
      • Organization accreditation must also be considered. Standards address compliance with federal and state regulations and may specify additional requirements for an RDN and/or NDTR.
      This description of supervision as it relates to the RDN/NDTR team is not synonymous with managerial supervision or oversight, clinical supervision used in medicine and mental health fields (eg, peer-to-peer), supervision of provisional licensees, and/or supervision of dietetic interns and students.

      Academy of Nutrition and Dietetics. Practice tips. What is meant by “under the supervision of the RDN.” http://www.eatrightstore.org/product/9E555AC7-ED41-445E-931C-C951BE0F14B3. Accessed December 1, 2017.

      In What Other Settings Do NDTRs Provide Services?

      Although many NDTRs work in clinical settings, career opportunities for NDTRs are not limited to clinical settings. CDR’s 2015 Practice Audit of entry-level nutrition and dietetics practitioners revealed the majority of NDTRs worked in foodservice systems management, long-term care, post-acute care facilities, and rehabilitation-care settings.
      • Griswold K.
      • Rogers D.
      • Sauer K.L.
      • Leibovitz
      • PK
      • Finn J.R.
      Entry-level dietetics practice today: Results from the 2015 Commission on Dietetic Registration entry-level dietetics practice audit.
      The NDTR’s role in providing food and nutrition services in nonclinical settings where an RDN may not be directly involved in the program/activity is guided by the NDTR’s individual scope of practice and requirements contained in regulations, employer or organizational policies and procedures, and state statutes and state practice acts. These settings include, but are not limited to, community-based nutrition programs, home-based programs, fitness centers, school nutrition programs, child nutrition programs, research, businesses, and foodservice systems management outside of health care settings. The SOPP and the Revised 2017 Scope of Practice for the NDTR
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered.
      clearly delineate expanded roles and opportunities for NDTRs.

      How Are the Standards Structured?

      Each of the standards is presented with a brief description of the competent level of practice. The rationale statement describes the intent, purpose, and importance of the standard. Indicators provide measurable action statements that illustrate applications of the standard and examples of outcomes depict measureable results that relate the indicators to practice. Each standard is equal in relevance and importance (see Figures 2 and 3, available at www.jandonline.org).

      How Can I Use the Standards to Evaluate and Advance My Practice and Performance?

      NDTRs should review the SOP in Nutrition Care and the SOPP at determined intervals. Regular self-evaluation is important because it helps identify opportunities to improve and enhance practice and professional performance. NDTRs are encouraged to pursue additional training and experience, regardless of practice setting, to maintain currency and to expand individual scope of practice within the limitations of the legal scope of practice, as defined in state law, if applicable, and federal and state regulations. Refer to Figure 4 for a flow chart that outlines how an NDTR can apply the SOP and SOPP to their practice.
      Figure 4Flow chart on how to use the Academy of Nutrition and Dietetics Standards of Practice and Standards of Professional Performance.
      Academy Scope of Practice for the Registered Dietitian Nutritionist (RDN)

      Academy Scope of Practice for the Nutrition and Dietetics Technician, Registered (NDTR)

      Scope of practice in nutrition and dietetics encompasses the range of roles, activities, and regulations within which nutrition and dietetics practitioners perform.

      Identify your individual scope of practice
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered.
      :

      An RDN’s and NDTR’s individual scope of practice is determined by education, training, credentialing, and demonstrated competence, as well as state statutory scope of practice, if applicable. Establishment of statutory scope of practice is the authority of the state(s) in which the RDN or NDTR practices. See Academy of Nutrition and Dietetics (Academy) Definition of Terms for differences between licensure, statutory certification, and title protection.
      • Review federal and state regulations and organizational policies and procedures.
      • Utilize Academy resources: Revised 2017 Scope of Practice for the RDN; Revised 2017 Scope of Practice for the NDTR; Academy/Commission on Dietetic Registration (CDR) Code of Ethics, Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for RDNs, Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for NDTRs, Scope of Practice Decision Tool, and the Academy Definition of Terms.
      Academy Standards of Practice in Nutrition Care and Standards of Professional Performance

      The four standards of practice in nutrition care and six standards of professional performance describe a minimum competent level of nutrition and dietetics practice and professional performance. Standards of practice and standards of professional performance are self-evaluation tools. Standards of practice in nutrition care apply to practitioners who provide care to patients/clients/populations.
      • Read the standards and rationale statements to determine how each relates to your practice. For NDTRs, identify direct patient/client care situations or activities that require working under the supervision of an RDN.
      Indicators

      Indicators are action statements that identify a minimum competent level of practice, demonstrate how each standard relates to practice, and link standards to outcomes.
      • Identify indicators that apply to your practice. Depending on your setting and work responsibilities, some indicators may not apply. Re-evaluate routinely and as responsibilities change.
      Examples of Outcomes for Each Standard

      The outcome statements illustrate examples of measurable actions that result from demonstrating competence in practice.
      • Review the outcome examples.
      • Evaluate measurable evidence of your performance to evaluate competence. Examples include documentation of outcomes from peer interactions, patient/client/customer/population interventions, customer service reports, and job responsibility deliverables.
      • Comply regularly with standards and indicators utilizing organizational policies, procedures, and protocols.
      How do I demonstrate competence in my practice? Take a continuous quality improvement approach to implementing the standards and achieving desirable outcomes. Re-evaluate on a regular basis.

      What do I need to do to enhance my practice? Use the standards to develop your Professional Development Portfolio. The CDR professional development recertification process provides a framework for the RDN and the NDTR to develop specific goals, identify essential practice competencies and performance indicators, and pursue continuing education opportunities. Incorporate your goals and essential practice competencies, practice illustrations, and actions into your annual performance review and learning development process.
      The standards can also be used as part of CDR’s Professional Development Portfolio process
      • Weddle D.O.
      • Himburg S.P.
      • Collins N.
      • Lewis R.
      The professional development portfolio process: Setting goals for credentialing.
      to develop goals and focus continuing education efforts. The Professional Development Portfolio process encourages CDR-credentialed nutrition and dietetics practitioners to incorporate self-reflection and learning needs assessment for development of a learning plan for improvement and commitment to lifelong learning. CDR’s updated system implemented with the 5-year recertification cycle that began in 2015 incorporates the use of essential practice competencies for determining professional development needs.
      • Worsfold L.
      • Grant B.L.
      • Barnhill C.
      The essential practice competencies for the Commission on Dietetic Registration’s credentialed nutrition and dietetics practitioners.
      In the 3-step process, the credentialed practitioner accesses an online Goal Wizard (step 1), which uses a decision algorithm to identify essential practice competency goals and performance indicators relevant to the NDTR’s area(s) of practice (essential practice competency goals and performance indicators replace the learning need codes of the previous process). The Activity Log (step 2) is used to log and document continuing professional education during a 5-year period. The Professional Development Evaluation (step 3) guides self-reflection and assessment of learning and how it is applied. The outcome is a completed evaluation of the effectiveness of the practitioner’s learning plan and continuing professional education. The self-assessment/self-evaluation information can then be used in developing the plan for the practitioner’s next 5-year recertification cycle. (For more information, see www.cdrnet.org/competencies-for-practitioners.)
      NDTRs use the SOP and SOPP as a self-evaluation tool to support and demonstrate quality and competence. NDTRs can:
      • apply every indicator and achieve the outcomes in line with roles and responsibilities all at once, or identify areas to strengthen and accomplish;
      • identify additional indicators and examples of outcomes (ie, outcomes measurement is a way to demonstrate value and competence) that reflect their individual practices/settings; and
      • apply only applicable indicators based on diversity of practice roles, activities, organization performance expectations, and work or volunteer practice settings.
      The standards are written in broad terms to allow for an individual practitioner's handling of nonroutine situations. The standards are geared toward typical situations for practitioners with the NDTR credential. Figure 5 provides role examples illustrating how NDTRs in a variety of settings can use the standards. Strictly adhering to standards does not, in and of itself, constitute best care and service. It is the responsibility of individual practitioners to recognize and interpret situations and to know what standards apply and in what way they apply.
      • Gates G.R.
      • Amaya L.
      Ethics opinion: Registered dietitian nutritionists and nutrition and dietetics technicians, registered are ethically obliged to maintain personal competencies in practice.
      Figure 5Examples of use of the Standards of Practice and Standards of Professional Performance for Nutrition and Dietetics Technicians, Registered for self-evaluation and the promotion of competent practice.
      RoleExamples of use of SOP and SOPP documents by NDTRs in different practice roles
      Food and nutrition services director/manager, long-term care facilityA nutrition and dietetics technician, registered (NDTR) accepts a position as the director/manager of dining services for a long-term care facility. The NDTR manages foodservice operations and assists the consulting registered dietitian nutritionist (RDN) by contributing information and observations (eg, screening data, diet history) for completing nutrition assessments and providing medical nutrition therapy as part of the health care team. The NDTR participates in care plan and discharge meetings; and responds to questions from residents and their families about the diet order, nutrition care plan, provision of nutrition supplements and snacks, and menu choices based on food preferences through collaboration with the consultant RDN as needed. The NDTR reports to the RDN on intervention responses, including documenting outcomes or providing evidence signifying a need to adjust the residents’ care plans. The NDTR updates professional development plan to incorporate competencies that address regulations, review of medical conditions, and nutrition care guidelines for population served by the facility, and foodservice-related skills.
      Clinical practitioner, hospital, inpatient careA hospital-based NDTR assigned to the cardiology and intensive care units assists the RDN following up on nutrition screening by obtaining additional information that the RDN will use to determine whether a nutrition assessment is indicated. The RDN and NDTR review patients, with the NDTR obtaining and contributing additional data to support assessments. For designated patients, the NDTR monitors for status changes, patient or family questions, care team observations, meal intake, and need for a snack, nutritional supplement, or nutrition education on therapeutic diet to contribute to care plan development/revision. The NDTR uses the Revised 2017 SOP in Nutrition Care and SOPP for NDTRs as the primary guide for self-evaluation to assess competent practice. The NDTR recognizes that this self-evaluation and review of nutrition and dietetics resources will assist in revising professional development plan to incorporate new essential competencies and to identify relevant continuing education activities.
      Nutrition practitioner, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinicAn NDTR who is a staff member in the health department’s WIC clinic screens participants for nutrition risk, assigns food packages or food package changes following guidelines, and provides nutrition education both individually and in group classes using approved nutrition education resources. The NDTR refers high-risk participants to the RDN for nutrition assessment and provides RDN-identified education to participants. The NDTR received initial and ongoing training from the RDN who provides consultation and performance monitoring. The NDTR’s goal is to provide breastfeeding counseling, assessment, and support and identifies specific continuing education activities with the goal of qualifying for the International Board Certified Lactation Consultant (IBCLC) certification. The NDTR updates professional development plan with applicable essential practice competencies.
      Director/manager, school nutrition programAn NDTR works as the public school district’s director of food and nutrition services. Working with school nutrition managers, the NDTR oversees foodservice operations. Tasks include documenting compliance with regulations, purchasing food and equipment, addressing food safety and sanitation, developing menus, training staff, and overseeing kitchen design and renovation, in addition to the human resource functions of the position. The NDTR facilitates addressing students’ required dietary modifications in consultation with families, school nurses, referring physicians, and the state agency consultant RDN, if needed. Because of the various roles, the NDTR uses the Revised 2017 SOP in Nutrition Care and SOPP for NDTRs as the guide for self-evaluation along with the state agency’s school nutrition professional development resources to reflect on any knowledge or skills needed for quality and competent practice.
      Telehealth practitioner, wellness organizationAn NDTR with more than 5 years hospital nutrition care experience accepts a position in the call center with a national organization that contracts with private insurers to provide virtual general health and wellness coaching to an insurer’s members. Call center staff, who are supervised by a registered nurse, are provided with extensive training that includes coaching skills and identifying when the caller needs to follow-up with a health care professional, for example, medical provider, a pharmacist with medication questions, or an RDN to address a prescribed diet for a chronic condition. The NDTR follows organization guidelines for providing general health, nutrition, and physical activity information to callers. With the change in employment to this new position, the NDTR reviews the Revised 2017 SOP in Nutrition Care and SOPP for NDTRs and updates professional development plan with new essential practice competencies, as needed.
      NDTR, nonpracticingAn NDTR takes a leave of absence from the nutrition and dietetics workforce. Because the NDTR is maintaining the credential, sustaining professional performance is an expectation. The NDTR maintains and establishes networking and professional relationships. The NDTR participates in, and volunteers for, the local and national nutrition and dietetics association. The NDTR volunteers with the community food bank and responds to public policy calls to action by contacting representatives via social media and e-mail. The NDTR obtains continuing professional education units for CDR certification requirement. The NDTR recognizes the need to maintain skills at least at the minimally competent level identified within the Revised 2017 SOP in Nutrition Care and SOPP for NDTRs.

      Summary

      NDTRs are challenged by complex situations every day. Competently addressing the unique needs of each situation and applying standards appropriately is essential to providing safe, timely, person-/client-/population-centered quality care and service. All NDTRs are advised to conduct their practice based on the most recent edition of the Academy/CDR Code of Ethics,
      American Dietetic Association/Commission on Dietetic Registration
      Code of Ethics for the Profession of Dietetics and process for consideration of ethical issues.
      the Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered.
      the Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for NDTRs, and the Academy Practice Tips.

      Academy of Nutrition and Dietetics. Practice tips: The RDN-NDTR team—Steps to preserve. http://www.eatrightstore.org/product/C6E60A2F-BCED-4F3F-BC55-9A99C6BF4002. Accessed December 1, 2017.

      Academy of Nutrition and Dietetics. Practice tips. What is meant by “under the supervision of the RDN.” http://www.eatrightstore.org/product/9E555AC7-ED41-445E-931C-C951BE0F14B3. Accessed December 1, 2017.

      These resources provide minimum standards as well as tools for demonstrating competence and safe practice, and are used collectively to gauge and guide an NDTR’s performance in nutrition and dietetics practice. The SOP and SOPP for the NDTR are self-evaluation tools that promote quality assurance, performance improvement, and outcomes management.

      Academy of Nutrition and Dietetics. Definition of terms. http://www.eatrightpro.org/scope. Accessed December 1, 2017.

      Self-evaluation provides opportunities to identify areas for enhancement, new learning, and skill development and to encourage progression of career growth.
      To ensure that NDTRs have ready access to the most current materials, each resource is maintained on or accessed through the Academy website. The documents are reviewed and updated as new trends in the profession of nutrition and dietetics, health care, public health, food science, and other external influences emerge.
      The standards have been formulated for use by individuals in self-evaluation, practice advancement, and for indicators of quality. These standards do not constitute medical or other professional advice and should not be taken as such. The information presented in the standards is not a substitute for the exercise of professional judgment by the nutrition and dietetics practitioner. The standards are not intended for disciplinary actions or determinations of negligence or misconduct. The use of the standards for any other purpose than that for which they were formulated must be undertaken with the sole authority and discretion of the user.

      Acknowledgements

      The Academy Quality Management Committee thanks the following Academy organizational units for their assistance with manuscript preparation: Academy Committees and Subcommittees, Academy Dietetic Practice Groups, Accreditation Council for Education in Nutrition and Dietetics (ACEND), Commission on Dietetic Registration (CDR), House of Delegates Leadership Team (HLT), and Nutrition and Dietetics Educators and Preceptors (NDEP).
      All members contributed material, reviewed the manuscript, and approved the final product.

      Supplementary Materials

      Figure 2Standards of Practice for Nutrition and Dietetics Technicians, Registered. Note: The terms patient, client, customer, individual, person, group, or population are used interchangeably with the actual term used in a given situation, depending on the setting and the population receiving care or services.
      Standards of Practice for Nutrition and Dietetics Technicians, Registered

      Standard 1: Participates in Nutrition Screening and Provides Support to Nutrition Assessment

      The nutrition and dietetics technician, registered (NDTR) participates in nutrition screening of patients/clients and populations and obtains and verifies relevant data and information for support of nutrition assessment under the supervision of the registered dietitian nutritionist (RDN).

      Rationale:

      Nutrition screening is the preliminary step to identify individuals who require a nutrition assessment performed by an RDN. Although nutrition assessment and reassessment are the responsibility of the RDN, the NDTR takes an active role in obtaining and verifying relevant data and information for the RDN to complete the assessment.
      Indicators for Standard 1: Participates in Nutrition Screening and Provides Support to Nutrition Assessment
      Each NDTR:
      1.1Conducts nutrition screening according to pre-established criteria and/or tools based in evidence and organizational policy to identify individuals with a nutrition-related problem (eg, but not limited to, risk for malnutrition, food allergy/intolerance, missing dentures)
      1.2Obtains food and nutrient administration and intake data
      1.2ACollects and reviews food and nutrient intake information (eg, current and previous diets, nutrition support, diet prescriptions, meal and snack patterns, medical foods/nutritional supplements, typical foods and beverages, cultural and religious preferences, and food allergies and intolerances)
      1.2BRecords food and nutrient intake data
      1.2CCalculates food and nutrient intake
      1.2DCompares calculated intake data to reference standards identified by the RDN
      1.2ESummarizes food and nutrient intake information
      1.3Conducts interviews and reviews records for the following data for patients/clients and populations
      1.3APersonal, medical, nutrition, oral health, family, and psychosocial/social history
      1.3BAnthropometric indicators (eg, height, weight, weight history, body mass index, waist circumference, growth pattern indices/percentile ranks/z scores)
      1.3CBiochemical data, medical tests, procedures, and evaluations
      1.3DMedication data (eg, prescription and over-the-counter medications; dietary supplements [see Academy Definition of Terms]; medication and supplement allergies; potential for medication/food interaction; and adherence)
      1.3EBehavior, beliefs, knowledge, and attitudes of patient/client/population that influence nutrition and health and understanding of medical and other conditions
      1.3FCognitive and physical ability to complete specific developmentally appropriate nutrition-related tasks (eg, self-feeding and other activities of daily living [ADLs]) and instrumental ADLs (eg, shopping and food preparation)
      1.3GPhysical activity habits, training, and restrictions
      1.3HFood security defined as factors affecting access to a sufficient quantity of safe, healthful food and water, as well as food/nutrition-related supplies
      1.3IOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial, and social determinants of health)
      1.4Communicates results of nutrition screening to RDN
      1.5Documents and communicates:
      1.5ADate and time of interview(s)
      1.5BDate and time of records and data review
      1.5CPertinent data (eg, food and nutrient intake, anthropometrics, biochemical data, medical tests and procedures, malnutrition, patient/client/population and medical, psychosocial, social, behavioral history)
      1.5DComparison to reference standards
      1.5EPatient/client/population perceptions, values, and motivation related to nutrition care
      1.5FPatient/client/population level of understanding, reported food-related behaviors, and other pertinent information
      Examples of Outcomes for Standard 1: Participates in Nutrition Screening and Provides Support to Nutrition Assessment
      • Effective interviewing methods are used
      • Appropriate data are collected and recorded
      • Data can be verified
      • Data are organized in a meaningful framework that relates to nutrition problems
      • Documentation is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and timed
      • Corrections to recorded data are made by approved methods
      Standard 2: Provides Support to Nutrition Diagnosis

      The nutrition and dietetics technician, registered (NDTR) obtains, verifies, and documents relevant data and information to support the registered dietitian nutritionist (RDN) in determining the nutrition diagnosis(es) or nutrition problems and etiology for patients/clients/populations. NDTRs observe and communicate signs and symptoms/defining characteristics, and other relevant information in a timely and accurate manner.

      Rationale:

      NDTRs contribute to the RDN’s identification of a nutrition diagnosis(es) by obtaining, verifying, documenting, and communicating relevant data and information about problem, etiology, signs, and symptoms for the RDN to effectively cluster, analyze, and synthesize information to determine a nutrition diagnosis(es). Timely and appropriate nutrition diagnosis by the RDN leads to a timely appropriate nutrition intervention/plan of care.
      Indicators for Standard 2: Provides Support to Nutrition Diagnosis
      Each NDTR:
      2.1Observes signs and symptoms/defining characteristics
      2.2Verifies signs and symptoms with patient/client/advocate
      Advocate: An advocate is a person who provides support or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision-making capacity. (Adapted from definitions within The Joint Commission Glossary of Terms4 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation5).
      /community, caregivers, family members, or other health care professionals when possible and appropriate
      2.3Documents signs and symptoms/defining characteristics
      2.4Communicates signs and symptoms/defining characteristics and other relevant information to the RDN
      Examples of Outcomes for Standard 2: Provide Support to Nutrition Diagnosis
      • Documentation of signs and symptoms is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and timed
      • Documentation of signs and symptoms is updated as additional data and information become available
      Standard 3: Provides Support to Nutrition Intervention/Plan of Care as Directed by the Registered Dietitian Nutritionist

      The nutrition and dietetics technician, registered (NDTR) works under the supervision of the registered dietitian nutritionist (RDN) and assists by contributing to the implementation of nutrition intervention/plan of care developed by the RDN. The person-centered nutrition intervention/plan of care is designed to maintain or promote a desirable change in nutrition-related behaviors, risk factors, environmental conditions, or aspects of health status for an individual, target group, or the community at large.

      Rationale:

      The NDTR contributes to the nutrition intervention/plan of care by assisting the RDN with implementation of individualized patient-/client-/population-centered nutrition interventions/plans of care and education with the goal of resolving, improving, or stabilizing the nutrition diagnosis/problem.
      Indicators for Standard 3: Provides Support to Nutrition Intervention/Plan of Care as Directed by the Registered Dietitian Nutritionist
      Each NDTR:
      3.1Provides nutrition intervention/plan of care as designed and directed by an RDN and in accordance with:
      3.1AApplicable laws and regulations
      3.1BOrganization or program, policies and procedures
      3.2Responds to patient/client/advocate/population inquiries regarding interventions that are within the established nutrition intervention/plan of care in accordance with the NDTR’s demonstrated competence
      3.3Communicates and clarifies the nutrition intervention/plan of care, including nutrition prescription with patients/clients/advocates/population, caregivers, and interprofessional
      Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient/client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team members
      3.4Verifies that the nutrition intervention/plan of care is being implemented and that needs and preferences of the patient/client/population are being met
      3.5Participates in discharge planning and transitions of care for patients/clients and populations
      3.6Communicates with RDN about discussions with patient/client/advocate/population and observed changes in patient/client/population status that may influence the nutrition intervention/plan of care and/or discharge planning/transitions of care needs
      3.7Documents and communicates:
      3.7ADate and time
      3.7BNutrition intervention/plan of care provided as developed by the RDN
      3.7CObserved changes in patient/client status influencing the nutrition intervention/plan of care
      3.7DPatient/client/advocate/caregiver/community receptiveness
      3.7EPatient/client/advocate/caregiver/community comprehension of intervention/plan of care
      3.7FObserved barriers to change
      3.7GPlans for follow-up
      Examples of Outcomes for Standard 3: Provides Support to Nutrition Intervention/Plan of Care as Directed by the RDN
      • Nutrition intervention/plan of care is implemented
      • Documentation of interventions are:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and timed
      • Patient/client food/nutrient provision (ie, menu, oral supplements, enteral nutrition support) reflects nutrition prescription
      • NDTR communicates with RDN regarding conversations with patient/client/advocate/population and observed changes in patient/client/population status that might influence the nutrition intervention/plan of care
      • NDTR participates in discharge planning and transitions of care per facility/department policy
      • Interprofessional team member connections are established
      Standard 4: Nutrition Monitoring and Evaluation

      The nutrition and dietetics technician, registered (NDTR) participates in the nutrition monitoring of patients/clients and populations under the supervision of the registered dietitian nutritionist (RDN). The NDTR uses indicators as identified by the RDN that are relevant to the defined needs, nutrition diagnosis/problem, nutrition goals, preferences, and desired health results for the patient/client/population.

      Rationale:

      Nutrition monitoring and evaluation are essential components of an outcomes management system in order to assure quality, patient-/client-/population-centered care and to promote uniformity within the profession in evaluating the efficacy of nutrition interventions. By obtaining nutrition data and information at scheduled follow-up points, the NDTR assists the RDN in nutrition monitoring to support evaluation of the nutrition intervention/plan of care and tailoring the nutrition intervention/plan of care to the patient’s/client’s/population’s needs and preferences.
      Indicators for Standard 4: Nutrition Monitoring and Evaluation
      Each NDTR:
      4.1Assesses patient/client/advocate/population understanding and compliance with nutrition intervention/plan of care
      4.2Determines whether the nutrition intervention/plan of care is being implemented as prescribed
      4.3Identifies data and information impacting the effectiveness of the nutrition intervention/plan of care strategy and potential needs after discharge
      4.4Communicates with the RDN regarding monitoring and evaluation activities and findings
      4.5Tracks and documents:
      4.5AProgress toward goals
      4.5BFactors/barriers impacting progress
      4.5CChanges in patient/client/advocate/population level of understanding and food-related behaviors
      4.5DChange in clinical data, health, or functional status and discharge/transitions of care needs
      4.5EOutcomes of intervention
      Examples of Outcomes for Standard 4: Provides Nutrition Monitoring and Supports Nutrition Evaluation
      • Timely observations and data collection by the NDTR inform the RDN that the nutrition intervention/plan of care is achieving desired outcomes or that revision is indicated
      • Documentation of monitoring may include:
        • Knowledge or understanding
        • Behavior
        • Intake of meals/snacks/nourishments, fluids (oral and intravenous), medical foods/nutritional supplements
        • Data for nutrition support therapies, eg, tube feedings and specialized intravenous nutrition solutions
        • Anthropomorphic measures, blood pressure, laboratory values
        • Oral health
        • Change of condition
        • Activities of daily living
        • Changes in diet prescription
        • Changes in medication
        • Changes in needs after discharge or for transitions of care
        • Satisfaction measurement
        • Communications with the RDN
      • Observed deviations in implementation of nutrition intervention/plan of care are reported to the RDN
      • Documentation of monitoring is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and timed
      a Advocate: An advocate is a person who provides support or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision-making capacity. (Adapted from definitions within The Joint Commission Glossary of Terms
      The Joint Commission
      Glossary.
      and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 151, 11-20-15); §482.28 Food and Dietetic Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed December 1, 2017

      ).
      b Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient/client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      Figure 3Standards of Professional Performance for Nutrition and Dietetics Technicians, Registered (NDTRs). Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean client/patient/customer, participant, consumer, or any individual, group, or organization to which the NDTR provides service.
      Standards of Professional Performance for Nutrition and Dietetics Technicians, Registered

      Standard 1: Quality in Practice

      The nutrition and dietetics technician, registered (NDTR) provides quality services using a systematic process with identified ethics, leadership, accountability, and dedicated resources.

      Rationale:

      Quality practice in nutrition and dietetics is built on a solid foundation of education, supervised practice (if applicable), credentialing, evidence-based practice, demonstrated competence, and adherence to established professional standards. Quality practice requires systematic measurement of outcomes, regular performance evaluations, and continuous improvement.
      Indicators for Standard 1: Quality in Practice
      Each NDTR:
      1.1Complies with applicable laws and regulations as related to his or her area(s) of practice
      1.2Performs within individual and statutory scope of practice and applicable laws and regulations
      1.3Adheres to sound business and ethical billing practices applicable to the role and setting
      1.4Uses national quality and safety data (eg, National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division, National Quality Forum, Institute for Healthcare Improvement) to improve the quality of services provided and to enhance customer-centered services
      1.5Uses a systematic performance improvement model that is based on practice knowledge, evidence, research, and science for delivery of the highest quality services
      1.6Participates in or designs an outcomes-based management system to evaluate safety, effectiveness, quality, person-centeredness, timeliness, and efficiency of practice
      1.6AInvolves colleagues and others, as applicable, in systematic outcomes management
      1.6BDefines expected outcomes that may include quality indicators identified by the RDN when providing patient/client care
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)
      1.6DMeasures quality of services in terms of structure, process, and outcomes
      1.6EReviews reports from electronic clinical quality measures that evaluate care improvement for patients/clients at risk for malnutrition or with malnutrition (www.eatrightpro.org/emeasures)
      1.6FDocuments measureable outcomes
      1.7Identifies and addresses potential and actual errors and hazards in provision of services or brings to attention of supervisors (eg, RDN) and team members as appropriate
      1.8Compares actual performance to performance goals (ie, Gap Analysis, SWOT Analysis [Strengths, Weaknesses, Opportunities, and Threats], PDCA Cycle [Plan-Do-Check-Act], DMAIC [Define, Measure, Analyze, Improve, Control])
      1.8AReports and documents action plan to address identified gaps in care and/or service performance
      1.9Checks interventions and workflow process(es) and identifies needed service and delivery improvements
      1.10Improves or enhances patient/client/population care and/or services working with RDN or others based on measured outcomes and established goals
      Examples of Outcomes for Standard 1: Quality in Practice
      • Actions are within scope of practice and applicable laws and regulations
      • National quality standards and best practices are evident in customer-centered services
      • Performance improvement program specific to program(s)/service(s) is established and updated as needed; is evaluated for effectiveness in providing desired outcomes data and striving for excellence in collaboration with RDN or other team members as indicated
      • Performance indicators are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)
      • Aggregate outcomes results meet pre-established criteria and/or goals
      • Quality improvement results direct refinement and advancement of practice
      Standard 2: Competence and Accountability

      The nutrition and dietetics technician, registered (NDTR) demonstrates competence in, and accepts accountability and responsibility for ensuring safe, quality practice and services.

      Rationale:

      Competence and accountability in practice includes continuous acquisition of knowledge, skills, experience, and judgment in the provision of safe, quality customer-centered service.
      Indicators for Standard 2: Competence and Accountability
      Each NDTR:
      2.1Adheres to the codes(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)
      2.2Integrates Scope of Practice, Standards of Practice (SOP), and Standards of Professional Performance (SOPP) into practice, self-evaluation, and professional development
      2.2AIntegrates applicable focus area SOP and SOPP into practice as directed by the RDN
      2.3Demonstrates and documents competence in practice and delivery of customer-centered service(s)
      2.4Assumes accountability and responsibility for actions and behaviors
      2.4AIdentifies, acknowledges, and corrects errors
      2.5Conducts self-evaluation at regular intervals
      2.5AIdentifies needs for professional development
      2.6Designs and implements plans for professional development
      2.6ADevelops plan and documents professional development activities in career portfolio (eg, organizational policies and procedures, credentialing agency[ies])
      2.7Engages in evidence-based practice and uses best practices
      2.8Participates in peer review of others as applicable to role and responsibilities
      2.9Mentors and/or precepts others
      2.10Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations, and requirements of practice setting
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects
        • Codes of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)
        • Scope of Practice, Standards of Practice, and Standards of Professional Performance
        • Evidence-based practice and best practices
        • Commission on Dietetic Registration Essential Practice Competencies and Performance Indicators
      • Practice incorporates successful strategies for interactions with individuals/groups from diverse cultures and backgrounds
      • Competence is demonstrated and documented
      • Services provided are safe and customer-centered
      • Self-evaluations are conducted regularly to reflect commitment to lifelong learning and professional development and engagement
      • Professional development needs are identified and pursued
      • Directed learning is demonstrated
      • Relevant opportunities (education, training, credentials, certifications) are pursued to advance practice
      • Commission on Dietetic Registration recertification requirements are met
      Standard 3: Provision of Services

      The nutrition and dietetics technician, registered (NDTR) provides safe, quality service based on customer expectations and needs, and the mission, vision, principles, and values of the organization/business. The NDTR works under the supervision of a registered dietitian nutritionist (RDN) when providing services related to direct care.

      Rationale:

      Quality programs and services are designed, executed, and promoted based on the NDTR’s knowledge, skills, experience, judgment, and competence in addressing the needs and expectations of the organization/business and its customers.
      Indicators for Standard 3: Provision of Services
      Each NDTR:
      3.1Contributes to or leads in development and maintenance of programs/services that address the needs of the customer or target population(s)
      3.1AAligns program/service development with the mission, vision, principles, values, and service expectations and outputs of the organization/business
      3.1BUses the needs, expectations, and desired outcomes of customers/populations (eg, patients/clients, families, community, decision makers, administrators, client organization[s]) in program/service development
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environment
      3.1DProposes programs and services that are customer-centered, culturally appropriate, and minimize disparities
      3.2Promotes public access and referral to credentialed nutrition and dietetics practitioners for quality food and nutrition programs and services
      3.2AContributes to or designs referral systems that promote access to qualified, credentialed nutrition and dietetics practitioners
      3.2BRefers customers to appropriate providers when requested services or identified needs exceed the NDTR’s individual scope of practice
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomes
      3.3Contributes to or designs customer-centered services
      3.3ASets priorities based on needs, beliefs/values, goals, resources of the customer, and social determinants of health
      3.3BUses knowledge of the customer’s/target population’s health conditions, culture, beliefs, and business objectives/services to guide design and delivery of customer-centered services
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target population
      3.3DCollaborates with customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomes
      3.3EInvolves customers in decision making
      3.4Executes programs/services in an organized, collaborative, cost effective, and customer-centered manner
      3.4ACollaborates and coordinates with RDN, peers, colleagues, stakeholders, and within interprofessional
      Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      teams
      3.4BUses and participates in, or leads in the selection, design, execution, and evaluation of customer programs and services (eg, nutrition screening system, medical and retail foodservice, electronic health records, interprofessional programs, community education, grant management)
      3.4CUses and develops or contributes to selection, design and maintenance of policies, procedures (eg, discharge planning/transitions of care), protocols, standards of care, technology resources (eg, Health Insurance Portability and Accountability Act [HIPAA] compliant telehealth platforms), and training materials that reflect evidence-based practice in accordance with applicable laws and regulations
      3.4DComplies with established billing regulations, organizational policies, grant funder guidelines, if applicable to role and setting, and adheres to ethical and transparent financial management and billing practices
      3.4ECommunicates with the interprofessional team and referring party consistent with the HIPAA rules for use and disclosure of customer’s personal health information
      3.5Uses professional, technical, and support personnel appropriately in the delivery of customer-centered care or services in accordance with laws, regulations, and organizational policies and procedures
      3.5AAssigns activities consistent with the qualifications, experience, and competence of professional, technical, and support personnel
      3.5BSupervises professional, technical, and support personnel
      3.6Designs and implements food delivery systems to meet the needs of customers
      3.6ACollaborates in or leads the design of food delivery systems to address health care needs and outcomes (including nutrition status), ecological sustainability, and to meet the culture and related needs and preferences of target populations (ie, health care patients/clients, employee groups, visitors to retail venues, schools, child and adult day-care centers, community feeding sites, farm-to-institution initiatives, local food banks)
      3.6BParticipates in, consults/collaborates with the RDN or others, or leads the development of menus to address health, nutritional, and cultural needs of target population(s) consistent with federal, state, or funding source regulations or guidelines
      3.6CProvides input to the RDN in the interprofessional process for determining medical foods/nutritional supplements, dietary supplements, enteral nutrition formulary for target population(s)
      3.7Maintains records of services provided
      3.7ADocuments according to organizational policies, procedures, standards, and systems, including electronic health records
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilization
      3.7CUses data to document outcomes of services (ie, staff productivity, cost/benefit, budget compliance, outcomes, quality of services) and provide justification for maintenance or expansion of services
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulations
      3.8Advocates for provision of food and nutrition services as part of public policy
      3.8ACommunicates with policy makers regarding the benefit/cost of quality food and nutrition services
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditions
      3.8CAdvocates for protection of the public through multiple avenues of engagement (eg, legislative action, establishing effective relationships with elected leaders and regulatory officials, participation in various Academy committees, workgroups and task forces, Dietetic Practice Groups, Member Interest Groups, and State Affiliates)
      Examples of Outcomes for Standard 3: Provision of Services
      • Program/service design and systems reflect organization/business mission, vision, principles, and values, and customer needs and expectations
      • Customers participate in establishing program/service goals and customer-focused action plans and/or nutrition interventions (eg, in-person or via telehealth)
      • Customer-centered needs and preferences are met
      • Customers are satisfied with services and products
      • Customers have access to food assistance
      • Customers have access to food and nutrition services
      • Foodservice system incorporates sustainability practices addressing energy and water use, and waste management
      • Menus reflect the cultural, health, and/or nutritional needs of target population(s) and consideration of ecological sustainability
      • Evaluations reflect expected outcomes and established goals
      • Effective screening and referral services are established or implemented as designed
      • Professional, technical, and support personnel are supervised consistent with role and responsibilities
      • NDTR collaborates with an RDN and receives supervision when providing nutrition care to customers
      • Ethical and transparent financial management and billing practices are used per role and setting
      Standard 4: Application of Research

      The nutrition and dietetics technician, registered (NDTR) participates in and/or applies research to enhance practice. Evidence-based practice incorporates the best available research/evidence and information in the delivery of nutrition and dietetics services.

      Rationale:

      Participation in and application of nutrition and dietetics research leads to improved safety and quality of nutrition and dietetics practice and services.
      Indicators for Standard 4: Application of Research
      Each NDTR:
      4.1Reviews best available research/evidence and information for application to practice
      4.1AUnderstands basic research design and methodology
      4.2Uses best available research/evidence and information as the foundation for evidence-based practice
      4.3Applies best available research/evidence and information with best practices, clinical and managerial expertise, and customer values
      4.4Contributes ideas and assists in activities of the research team
      Examples of Outcomes for Standard 4: Application of Research
      • Evidence-based practice, best practices, clinical and managerial expertise, and customer values are integrated in the delivery of nutrition and dietetics services
      • Customers receive appropriate services based on the effective application of best available research/evidence and information
      • Best available research/evidence and information is used as the foundation of evidence-based practice
      Standard 5: Communication and Application of Knowledge

      The nutrition and dietetics technician, registered (NDTR) effectively applies knowledge in communications.

      Rationale:

      The NDTR employs strategies and through collaboration with others, works to achieve common goals by effectively sharing and applying knowledge and skills in food, nutrition, dietetics, and management services.
      Indicators for Standard 5: Communication and Application of Knowledge
      Each NDTR:
      5.1Communicates and applies current knowledge and information based on evidence
      5.1ADemonstrates critical thinking and problem-solving skills when communicating with others
      5.2Selects appropriate information and the most effective method or format that considers customer-centered care and needs of the individual/group/population when communicating information and conducting nutrition education or promotion
      5.2AUses communication methods (ie, oral, print, one-on-one, group, visual, electronic, and social media) targeted to various audiences
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision making
      5.3Applies and demonstrates knowledge of food and nutrition integrated with knowledge of health, culture, social sciences, communication, informatics, sustainability, and management
      5.4Shares current, evidence-based knowledge, and information with various audiences
      5.4AGuides customers, families, students, and interns in the application of knowledge and skills
      5.4BAssists individuals and groups to identify and secure appropriate and available nutrition and lifestyle education and other resources and services
      5.4CUses professional writing and verbal skills in all types of communication
      5.4DReflects knowledge of population characteristics in communication methods
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management teams, organization, and community
      5.6Seeks opportunities to participate in and assume leadership roles with local, state, and national professional and community-based organizations (eg, government-appointed advisory boards, community coalitions, schools, foundations or nonprofit organizations serving the food insecure)
      Examples of Outcomes for Standard 5: Communication and Application of Knowledge
      • Expertise in food, nutrition, dietetics, and management is demonstrated and shared
      • Interoperable information technology is used to support practice
      • Effective and efficient communications occur through appropriate and professional use of e-mail, texting, and social media tools
      • Individuals, groups, and stakeholders:
        • Receive current and appropriate information and customer-centered service
        • Demonstrate understanding of information and behavioral strategies received
        • Know how to obtain additional guidance from the RDN or other RDN-recommended resources
      • Leadership is demonstrated through active professional and community involvement
      Standard 6: Utilization and Management of Resources

      The nutrition and dietetics technician, registered (NDTR) uses resources effectively and efficiently.

      Rationale:

      The NDTR demonstrates and applies leadership skills through strategic management of time, finances, facilities, supplies, technology, natural, and human resources.
      Indicators for Standard 6: Utilization and Management of Resources
      Each NDTR:
      6.1Uses a systematic approach to manage resources and improve outcomes
      6.2Evaluates management of resources with the use of standardized performance measures and benchmarking as applicable
      6.2AUses the Standards of Excellence Metric Tool, consistent with roles and responsibilities, to self-assess quality in leadership, organization, practice, and outcomes for an organization (www.eatrightpro.org/excellencetool)
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and products
      6.4Participates in quality assurance and performance improvement and documents outcomes and best practices relative to resource management
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators)
      Examples of Outcomes for Standard 6: Utilization and Management of Resources
      • Resources are effectively and efficiently managed
      • Documentation of resource use is consistent with operational and sustainability goals
      • Data are used to promote, improve, and validate services, organization practices, and public policy
      • Desired outcomes are achieved, documented, and disseminated
      • Identifies and tracks key performance indicators in alignment with organizational mission, vision, principles, and values
      a Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.

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