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From the Academy Standards of Practice and Professional Performance| Volume 121, ISSUE 10, P2071-2086.e59, October 01, 2021

Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support

      Abstract

      Nutrition support is a therapy that crosses all ages, diseases, and conditions as health care practitioners strive to meet the nutritional requirements of individuals who are unable to meet nutritional and/or hydration needs with oral intake alone. Registered dietitian nutritionists (RDNs), as integral members of the nutrition support team provide needed information, such as identification of malnutrition risk, macro- and micronutrient requirements, and type of nutrition support therapy (eg, enteral or parenteral), including the route (eg, nasogastric vs nasojejunal or tunneled catheter vs port). The Dietitians in Nutrition Support Dietetic Practice Group, American Society for Parenteral and Enteral Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nutrition support. The SOP and SOPP for RDNs in Nutrition Support provide indicators that describe the following 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nutrition support and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.
      Editor’s note: Figures 1 and 2 that accompany this article are available online at www.jandonling.org.
      The Dietitians in Nutrition Support Dietetic Practice Group (DNS DPG) of the Academy of Nutrition and Dietetics (Academy), and members of the Dietetics Practice Section of the American Society for Parenteral and Enteral Nutrition (ASPEN), under the guidance of the Academy Quality Management Committee and ASPEN Clinical Practice Committee, have revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Nutrition Support previously published in 2014.
      • Brantley S.L.
      • Russell M.K.
      • Mogensen K.M.
      • et al.
      American Society for Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support.
      ,
      • Brantley S.L.
      • Russell M.K.
      • Mogensen K.M.
      • et al.
      American Society for Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support.
      The revised document, Academy of Nutrition and Dietetics and American Society for Enteral and Parenteral Nutrition: Revised 2021 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support, reflects advances in nutrition support practice during the past 7 years and replace the 2014 Standards. This document builds on the Academy of Nutrition and Dietetics: 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.
      The Academy of Nutrition and Dietetics/Commission on Dietetic Registration’s (CDR) Code of Ethics for the Nutrition and Dietetics Profession
      Academy of Nutrition and Dietetics/Commission on Dietetic Registration (CDR)
      2018 Code of Ethics for the Nutrition and Dietetics Profession. Academy of Nutrition and Dietetics.
      along with the Academy of Nutrition and Dietetics: 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.
      and Revised 2017 Scope of Practice for the RDN,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      guide the practice and performance of RDNs in all settings. ASPEN documents that guide the practice and performance of RDNs in nutrition support practice include the ASPEN Board of Directors-approved clinical guidelines, standards, clinical recommendations, and position papers, accessible at www.nutritioncare.org.
      Scope of practice in nutrition and dietetics is composed of statutory and individual components, includes the code(s) of ethics (eg, Academy/CDR, other national or international organizations, and/or employers code of ethics), and encompasses the range of roles, activities, practice guidelines, and regulations within which RDNs perform. For credentialed practitioners who practice in a state with professional licensure or certification, scope of practice is typically established within the practice act and associated regulations, and interpreted and controlled by the agency or board that regulates the practice of the profession in a given state.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      An RDN’s statutory scope of practice can delineate the services an RDN is authorized to perform in a state where a practice act or certification exists. For more information, see www.eatrightpro.org/advocacy/licensure/licensure-map.
      The RDN’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 breadth of the individual’s professional practice. Professional advancement beyond the core education and supervised practice to qualify for the RDN credential provides RDNs practice opportunities, such as expanded roles within an organization based on training and certifications, if required; or additional credentials (eg, focus area CDR specialist certification, if applicable, such as the Board Certified Specialist in Pediatric Critical Care Nutrition [CSPCC], and/or Advanced Practitioner Certification in Clinical Nutrition [RDN-AP]; Certified Nutrition Support Clinician [CNSC], Certified Case Manager [CCM], Certified Clinical Transplant Dietitian [CCTD], Nutrition Wound Care Certified [NWCC], and Certified Wound Specialist [CWS]). The Scope of Practice Decision Algorithm (www.eatrightpro.org/scope) guides an RDN through a series of questions to determine whether a particular activity is within their scope of practice. The algorithm is designed to assist an RDN to critically evaluate their personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.
      Scope of Practice Decision Algorithm
      Academy of Nutrition and Dietetics.
      All registered dietitians are nutritionists—but not all nutritionists are registered dietitians. The Academy's Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian (RD) may optionally use “Registered Dietitian Nutritionist” (RDN). The 2 credentials have identical meanings. In this document, the authors have chosen to use the term RDN to refer to both registered dietitians and registered dietitian nutritionists.
      Approved May 2021 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy), the Executive Committee of the Dietitians in Nutrition Support Dietetic Practice Group of the Academy, and the Clinical Practice Committee and the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN). Scheduled review date: May 2027. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Nutrition Support may be addressed to Academy Quality Management Staff: Dana Buelsing, MS, manager, Quality Standards Operations; and Carol J. Gilmore, MS, RDN, LD, FADA, FAND, scope/standards of practice specialist, Quality Management at [email protected].
      The Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, Hospital
      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02 21 20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      and Critical Access Hospital
      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02 21 20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      Conditions of Participation allow a hospital and its medical staff the option of including RDNs or other clinically qualified nutrition professionals within the category of “non-physician practitioners” eligible for ordering privileges for therapeutic diets and nutrition-related services if consistent with state law and health care regulations. RDNs in hospital settings interested in obtaining ordering privileges must review state laws (eg, licensure, certification, and title protection), if applicable, and health care regulations to determine whether there are any barriers or state-specific processes that must be addressed. For more information, review the Academy’s practice tips that outline the regulations and implementation steps for obtaining ordering privileges (www.eatrightpro.org/dietorders/). For assistance, refer questions to the Academy’s State Affiliate organization.
      Medical staff oversight of an RDN(s) occurs in 1 of 2 ways. A hospital has the regulatory flexibility to appoint an RDN(s) to the medical staff and grant the RDN(s) specific nutrition ordering privileges, or can authorize the ordering privileges without appointment to the medical staff. To comply with regulatory requirements, an RDN’s eligibility to be considered for ordering privileges must be through the hospital’s medical staff rules, regulations, and bylaws, or other facility-specific process.
      42 CFR Parts 413, 416, 440 et al. Medicare and Medicaid Programs; Regulatory provisions to promote program efficiency, transparency, and burden reduction; Part II; Final rule (FR DOC #2014-10687; pp 27106-27157). US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      The actual privileges granted may vary due to state law and the organization and medical staff along with the RDN’s knowledge, skills, experience, and specialist certification, if required, and demonstrated and documented competence.
      The “Long-Term Care Final Rule” published October 4, 2016 in the Federal Register, now “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.
      Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872) – 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). US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      The qualified professional must be acting within the scope of practice as defined by state law; and is under the supervision of the physician that may include, for example, countersigning the orders written by the qualified dietitian or clinically qualified nutrition professional. RDNs who work in long-term care facilities should review the Academy’s updates on CMS that outline the regulatory changes to §483.60 Food and Nutrition Services (www.eatrightpro.org/practice/quality-management/national-quality-accreditation-and-regulations/centers-for-medicare-and-medicaid-services). Review the state’s long-term care regulations to identify potential barriers to implementation; and identify considerations for developing the facility’s processes with the medical director and for orientation of attending physicians. The CMS State Operations Manual, Appendix PP-Guidance for Surveyors for Long-Term Care Facilities contains the revised regulatory language (new revisions are italicized and in red color).
      State Operations Manual. Appendix PP Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at www.cms.gov/files/document/som107appendicestoc.pdf.

      Academy Quality and Practice Resources

      The Academy’s 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.
      reflect the minimum competent level of nutrition and dietetics practice and professional performance. The core standards serve as blueprints for the development of focus area SOP and SOPP for RDNs in competent, proficient, and expert levels of practice. The SOP in Nutrition Care is composed of 4 standards consistent with the Nutrition Care Process (NCP) and clinical workflow elements as applied to the care of patients/clients/populations in all settings.
      • 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 consist of standards representing 6 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. The SOP and SOPP for RDNs are designed to promote the provision of safe, effective, efficient, equitable, and quality food and nutrition care and services; facilitate evidence-based practice; and serve as a professional evaluation resource.
      These focus area standards for RDNs in nutrition support provide a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering nutrition support care and services. They are used by RDNs to assess their current level of practice and to determine the education and training required to maintain currency in their focus area and advancement to a higher level of practice. In addition, the standards can be used to assist RDNs in general clinical practice with maintaining minimum competence in the focus area, and by RDNs transitioning their knowledge and skills to a new focus area of practice. Like the Academy’s core 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.
      the indicators (ie, measurable action statements that illustrate how each standard can be applied in practice) (see Figures 1 and 2, available at www.jandonline.org or https://onlinelibrary.wiley.com/journal/19412452) for the SOP and SOPP for RDNs in Nutrition Support were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in Nutrition Support were reviewed and approved by the Executive Committee of the DNS DPG, the ASPEN Clinical Practice Committee and Board of Directors, and the Academy Quality Management Committee.

      Three Levels of Practice

      The Dreyfus model
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer.
      identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (refer to Figure 3) during the acquisition and development of knowledge and skills. The first 2 levels are components of the required didactic education (novice) and supervised practice experience (advanced beginner) that precede credentialing for nutrition and dietetics practitioners. Upon successfully attaining the RDN credential, a practitioner enters professional practice at the competent level and manages their professional development to achieve individual professional goals. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDNs in Nutrition Support. In Academy focus areas, the 3 levels of practice are represented as competent, proficient, and expert.
      With safety and evidence-based practice
      Definition of Terms. Academy of Nutrition and Dietetics.
      as guiding factors when working with patients/clients/customers/populations, the RDN identifies the level of evidence, clearly states research limitations, provides safety information from reputable sources, and describes the risk of the intervention(s), when applicable.
      The Academy offers the Evidence Analysis Library (www.andeal.org/) as a resource, which provides a synthesis of systematic reviews on a variety of nutrition and dietetics topics, such as malnutrition in older adults, hydration, and preterm infant enteral nutrition guideline. The RDN is responsible for searching literature and assessing the level of evidence to select the best available evidence to inform recommendations. RDNs must evaluate and understand the best available evidence in order to converse authoritatively with the interprofessional team and adequately involve the patient/client/customer/population in shared decision making.
      Figure 3Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Nutrition Support. Image adapted from the Dietetics Career Development Guide, with permission.
      Standards of Practice (SOP) are authoritative statements that describe practice demonstrated through nutrition assessment, nutrition diagnosis (problem identification), nutrition intervention (planning, implementation), and outcomes monitoring and evaluation (4 separate standards) and the responsibilities for which RDNs are accountable. The SOP for RDNs in Nutrition Support presuppose that the RDN uses critical thinking skills; analytical abilities; theories; best-available research findings; current accepted nutrition, dietetics, and medical knowledge; and the systematic holistic approach of the nutrition care process as they relate to the application of the standards. Standards of Professional Performance (SOPP) for RDNs in Nutrition Support are authoritative statements that describe behavior in the professional role, including activities related to Quality in Practice; Competence and Accountability; Provision of Services; Application of Research; Communication and Application of Knowledge; and Utilization and Management of Resources (6 separate standards).
      SOP and SOPP are complementary standards and serve as evaluation resources. All indicators may not be applicable to all RDNs’ practice or to all practice settings and situations. RDNs operate within the directives of applicable federal and state laws and regulations, as well as policies and procedures established by the organization in which they are employed. To determine whether an activity is within the scope of practice of the RDN, the practitioner compares their knowledge, skill, experience, judgment, and demonstrated competence with the criteria necessary to perform the activity safely, ethically, legally, and appropriately. The Academy’s Scope of Practice Decision Algorithm is specifically designed to assist practitioners with this process.
      The term patient/client is used in the SOP as a universal term as these Standards relate to direct provision of nutrition care and services. Patient/client could also mean client/patient, resident, participant, consumer, or any individual or group who receives nutrition support therapy care and services. Customer is used in the SOPP as a universal term. Customer could also mean client/patient, client/patient/customer, participant, consumer, or any individual, group, or organization to which the RDN provides services. These services are provided to individuals of all ages. The SOP and SOPP are not limited to the clinical setting. In addition, it is recognized that the family and caregiver(s) of patient/clients of all ages, including individuals with special health care needs, play critical roles in overall health and are important members of the team throughout the assessment and intervention process. The term appropriate is used in the standards to mean: Selecting from a range of best practice or evidence-based possibilities, one or more of which would give an acceptable result in the circumstances.
      Each standard is equal in relevance and importance and includes a definition, a rationale statement, indicators, and examples of desired outcomes. A standard is a collection of specific outcome-focused statements against which a practitioner’s performance can be assessed. The rationale statement describes the intent of the standard and defines its purpose and importance in greater detail. Indicators are measurable action statements that illustrate how each specific standard can be applied in practice. Indicators serve to identify the level of performance of competent practitioners and to encourage and recognize professional growth.
      Standard definitions, rationale statements, core indicators, and examples of outcomes found in the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs have been adapted to reflect 3 levels of practice (competent, proficient, and expert) for RDNs in nutrition support (see image below). In addition, the core indicators have been expanded to reflect the unique competence expectations for the RDN providing nutrition support therapy.
      Standards described as proficient level of practice in this document are not equivalent to the National Board for Nutrition Support Certification, Certified Nutrition Support Clinician (CNSC). Rather, the CNSC designation recognizes the skill level of an RDN who has developed and demonstrated through successful completion of the certification examination, nutrition support knowledge and application beyond the competent practitioner and demonstrates, at a minimum, proficient-level skills. An RDN with a CNSC designation is an example of an RDN who has demonstrated additional knowledge, skills, and experience in nutrition support by the attainment of a specialist credential.

      Competent Practitioner

      In nutrition and dietetics, a competent practitioner is an RDN who is either just starting practice after having obtained RDN registration by CDR or an experienced RDN recently transitioning their practice to a new focus area of nutrition and dietetics. A focus area of nutrition and dietetics practice is a defined area of practice that requires focused knowledge, skills, and experience that apply to all levels of practice.
      Definition of Terms. Academy of Nutrition and Dietetics.
      A competent practitioner who has achieved credentialing as an RDN and is starting in professional employment consistently provides safe and reliable services by employing appropriate knowledge, skills, behavior, and values in accordance with accepted standards of the profession; acquires additional on-the-job skills; and engages in tailored continuing education to further enhance knowledge, skills, and judgment obtained in formal education.
      Definition of Terms. Academy of Nutrition and Dietetics.
      A general practice RDN can include responsibilities across several areas of practice, including, but not limited to, community; clinical; consultation and business; research; education; and food and nutrition management.
      For delivery of quality and safe nutrition support therapy (enteral nutrition [EN] or parenteral nutrition [PN]), specific knowledge and skills are required when providing care and services to patients/clients needing nutrition support therapy. RDNs with limited experience providing EN and/or PN need to explore options for increasing knowledge and skills, particularly with PN, a high-risk medication according to the Institute for Safe Medication Practices.
      ISMP List of High-Alert Medications in Acute Care Settings. Institute for Safe Medication Practices.
      More in-depth knowledge is needed in areas such as PN indications,
      • Worthington P.
      • Balint J.
      • Bechtold M.
      • et al.
      When is parenteral nutrition appropriate?.
      PN venous access, PN ordering, fluid and electrolyte management, electrolyte disorders, micronutrient requirements, and drug–nutrient interactions, as well as monitoring for and preventing complications (eg, refeeding syndrome
      • DaSilva J.A.V.
      • Sores D.S.
      • Sabino K.
      • et al.
      ASPEN consensus recommendations for refeeding syndrome.
      ). The RDN entering into the area of nutrition support should seek out a more experienced RDN in nutrition support therapies as a mentor; reference Figure 4 for mentorship opportunities and programs. The competent-level RDN will gain crucial knowledge for safe and quality nutrition support practice by reading articles and books, attending webinars or conferences related to nutrition support, and accessing the Academy and ASPEN resources in Figure 4.
      Figure 4Resources for Registered Dietitian Nutritionists (RDNs) in Nutrition Support (not all-inclusive).
      ResourceAddressDescription
      Academy of Nutrition and Dietetics (Academy) Resources
      Academy of Nutrition and Dietetics Dietitians in Nutrition Support Dietetic Practice Group (DNS DPG)https://www.dnsdpg.org/This DPG focuses on the science and practice of enteral and parenteral nutrition to provide evidence-based nutrition support therapy to individuals throughout the lifespan. The DPG provides resources to its members such as a newsletter, educational opportunities such as the DNS store, webinars with continuing education, symposium, podcasts, and a mentorship program.
      Academy of Nutrition and Dietetics Evidence Analysis Librarywww.andeal.orgThis website provides evidence-based nutrition practice guidelines and systematic reviews concerning nutrition support and related topics, such as malnutrition in older adults, cystic fibrosis, and preterm infant enteral nutrition.
      Case Study: RDN to Write Independent Parenteral Nutrition (PN)/Enteral Nutrition (EN) Ordershttps://www.eatrightstore.org/product-type/case-studies-and-practice-tips/case-study-independent-parenteral-nutrition-and-enteral-nutrition-orders“This case study explores the situation in which a registered dietitian nutritionist requests privileges to write independent orders for parenteral nutrition and enteral nutrition. Guidance, resources and options are provided that can be used to evaluate whether the RDN can safely and effectively provide an expanded practice skill and advance individual practice.”
      Clinical Malnutritionhttps://www.eatrightpro.org/practice/practice-resources/clinical-malnutritionThis webpage includes information for RDNs including the Malnutrition Quality Improvement Initiative (MQii), malnutrition resources from the Academy (eg, malnutrition coding, nutrition-focused physical exam training), and malnutrition resources from other organizations (eg, Canadian Malnutrition Task Force, Defeat Malnutrition Today).
      Enteral Feeding: What I Wish I Knew When I Started Out in Practicehttps://www.eatrightstore.org/cpe-opportunities/online-courses/enteral-feeding-what-i-wish-i-knew-when-i-started-out-in-practiceThis webinar outlines gastrointestinal physiology in the context of enteral nutrition delivery and dispels many myths surrounding signs and symptoms of what is referred to as “intolerance” of enteral nutrition.
      Mentoring or Career Guidance Opportunitieshttps://www.eatrightpro.org/membership/academy-groups/dietetic-practice-groups/mentoring-or-career-guidance-opportunitiesThis webpage provides mentoring resources specific to the Academy’s DPGs. This page includes a link to the Academy eMentoring and Mentoring Resources page, which provides resources for identifying a mentor and building mentor/mentee relationships. In addition, Academy members may enroll in Mentor Match, which matches Academy members with a mentor or mentee who best fits the professional areas of interest, communication style, and availability.
      Optimizing the Transition from Acute to Home Enteral Nutritionhttps://www.eatrightstore.org/collections/fnce-2019/194-optimizing-the-transition-from-acute-to-home-enteral-nutritionThis education session discusses the RDN’s role in establishing an appropriate care plan and how that plan can be continued at home for a smooth and effective continuum of care working with the interprofessional team.
      Pocket Guide to Enteral Nutrition, 2nd editionhttps://www.eatrightstore.org/product-type/pocket-guides/academy-pocket-guide-to-enteral-nutrition-2edThis guide provides comprehensive information regarding enteral nutrition, such as indications/contraindications, patient assessment, enteral access, and feeding initiation, advancement, and transition. It also includes information about how to apply the Nutrition Care Process as it relates to enteral nutrition.
      Pocket Guide to Parenteral Nutrition, 2nd editionhttps://www.eatrightstore.org/product-type/ebooks/pocket-guide-to-parenteral-nutrition-second-edition-ebookThis guide provides information on indications for parenteral nutrition, determining parenteral nutrition nutrients, vascular access, initiation and advancement of parenteral nutrition, patient/client monitoring, and coordination of care. This resource also includes information about how to apply the Nutrition Care Process to parenteral nutrition.
      American Society for Parenteral and Enteral Nutrition (ASPEN) Resources
      Appropriate Dosing for Parenteral Nutrition: ASPEN Recommendationshttp://www.nutritioncare.org/uploadedFiles/Documents/Guidelines_and_Clinical_Resources/PN%20Dosing%201-Sheet-FINAL.pdfThis 3-page tool provides basic guidelines for dosing of macro- and micronutrients for adult, neonatal, and pediatric patients/clients receiving parenteral nutrition. It is to be used to assure that minimum nutrient needs are met to prevent deficiencies, particularly in the case of drug shortages.
      ASPEN eLearning Centerhttps://aspen.digitellinc.com/aspen/This website provides the various eLearning resources related to enteral and parenteral nutrition provided by ASPEN. Resources include items such as journal continuing education, webinar recordings, podcasts, conference recordings, and online courses.
      ASPEN Enteral Nutrition Handbook, 2nd editionhttp://www.nutritioncare.org/ENHandbook/This book gives evidenced-based practice recommendations for the clinician providing enteral nutrition. It delivers comprehensive information on enteral nutrition for the adult and pediatric patient/client.
      ASPEN Fluids, Electrolytes, and Acid-Based Disorders Handbook, 2nd editionhttps://portal.nutritioncare.org/bookstore-details?id=0eac1493-80e3-4429-9fd5-3d2fe08522d4This book provides guidance on issues such as managing electrolyte balance, treatment of sodium disorders, and maintenance of hydration. This book includes information on adult and pediatric patients/clients.
      ASPEN Guidelines and Clinical Resourceshttps://www.nutritioncare.org/guidelines_and_clinical_resources/This website provides guidelines, publications, and clinical resources to assist in providing safe, quality nutrition care to patients/clients. Resources include books, journals, enteral and parenteral nutrition resources, Malnutrition Solutions Center, and Clinical Practice Library, which includes clinical guidelines, consensus recommendations, position papers, and standards.
      ASPEN Nutrition Support Fundamentals Coursehttp://www.nutritioncare.org/NSFC/This course provides the attendee with the fundamentals of nutrition support and is used in preparation for obtaining the Nutrition Support Certification as a Certified Nutrition Support Clinician. It is a tool also used to identify personal knowledge gaps and guide future areas of learning.
      A.S.P.E.N. Parenteral Nutrition Workbookhttps://portal.nutritioncare.org/bookstore-details?id=37899a99-aa57-4aa6-8564-b0ee552910b9This resource is designed to improve competency with parenteral nutrition prescribing and order writing. This practical workbook provides case studies to guide the reader through real-world clinical situations. It is intended for varying levels of practice, including students.
      Guidebook on Enteral Medication Administrationhttp://www.nutritioncare.org/ENMedicationGuidebook/This guidebook provides comprehensive information on medication delivery via feeding tubes. It gives providers such as RDNs, pharmacists, nurses, and physicians crucial information on how to give medication via feeding tubes.
      The ASPEN Adult Nutrition Support Core Curriculum, 3rd editionhttps://store.ashp.org/Default.aspx?TabID=251&productId=617828804This book provides information regarding the fundamentals of nutrition support. It also gives nutrition support recommendations for certain medical conditions, as well as case scenarios to facilitate learning.
      The ASPEN Parenteral Nutrition Handbook, 3rd editionhttps://portal.nutritioncare.org/bookstore-details?id=9c8a6b20-5f45-48e7-8d7e-892a615886ff&index=26&reload=timezoneThis book provides information on the fundamentals of parenteral nutrition including, but not limited to, competency, order review, compounding, and management of drug shortages.
      The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2nd editionhttps://portal.nutritioncare.org/bookstore-details?id=90ea43d1-dae3-4914-baf7-47fb51528b48This Core Curriculum provides detailed information about pediatrics from infancy through adolescence. It contains chapters that explain the use of enteral and parenteral nutrition in the pediatric population, such as how to determine nutrient needs, how to select the most appropriate access device, administration of nutrition support, and monitoring the effectiveness of nutrition support.
      Professional Websites
      Clinical Care Nutritionhttps://www.criticalcarenutrition.com/Clinical Care Nutrition aims to improve nutrition therapies in the critical care setting through research that will translate into improved clinical outcomes for critically ill patients.
      European Society for Clinical Nutrition and Metabolism (formerly European Society for Parenteral and Enteral Nutrition)www.espen.orgThis European organization provides extensive information regarding the provision of enteral and parenteral nutrition. Resources include journals, trainings, electronic video library, books, and guidelines.
      National Board of Nutrition Support Certificationhttp://www.nutritioncare.org/nbnsc/The Certified Nutrition Support Clinician (CNSC) certification is available to RDNs, nurses, pharmacists, and physicians. It signifies these practitioners as proficient to practice in the area of nutrition support. An examination must be passed to receive this certification, and re-examination is required every 5 years to maintain the credential.
      North American Society for Pediatric Gastroenterology, Hepatology & Nutritionwww.naspghan.orgThis organization provides information regarding pediatric gastroenterology, hepatology, and nutrition in health and disease. Resources they provide include a journal, annual meeting, mentorship program, and advocacy efforts.
      Society of Critical Care Medicinewww.sccm.orgThis organization provides information regarding treatment of critically ill patients and develops guidelines that may be helpful to the nutrition support clinician. Resources also include webcasts, conferences, and knowledge education groups.

      Proficient Practitioner

      A proficient practitioner is generally 3 or more years beyond RDN credentialing and entry into the profession and consistently provides safe and reliable services; has obtained operational job performance skills; and is successful in the RDN's chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, judgment, and experience in a focus area of nutrition and dietetics practice. An RDN may acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice.
      Definition of Terms. Academy of Nutrition and Dietetics.
      The proficient-level RDN in nutrition support has gained more nutrition support-related clinical skills and knowledge above that of a competent practitioner and functions with more autonomy in managing patients requiring EN or PN. The proficient practitioner has sufficient, or is working towards sufficient, knowledge and qualifications through continuing education or practice hours in nutrition support in order to qualify for the CNSC,
      What is NBNSC? National Board of Nutrition Support Certification.
      RDN-AP, or CSPCC.

      Expert Practitioner

      An expert practitioner is an RDN recognized within the profession and has mastered the highest degree of skill in, and knowledge of, nutrition and dietetics. Expert-level achievement is acquired through ongoing critical evaluation of practice and feedback from others. The individual at this level strives for additional knowledge, experience, and training. An expert has the ability to quickly identify “what” is happening and “how” to approach the situation. Experts easily use nutrition and dietetics skills to become successful through demonstrating quality practice and leadership, and to consider new opportunities that build on nutrition and dietetics.
      Definition of Terms. Academy of Nutrition and Dietetics.
      An expert practitioner may have an expanded or specialist role, or both, and may possess an advanced credential(s), such as the CNSC, RDN-AP, and/or CSPCC. Generally, the practice is more complex, and the practitioner has a high degree of professional autonomy and responsibility. Expert-level RDNs in nutrition support serve as a principal source of information and guidance for RDN colleagues and interprofessional team members. They promote the practice and expertise needed for quality nutrition support practice through publications, speaking engagements, and serve the profession by participating in Academy and ASPEN organizations at the local, state, and/or national level. Expert-level RDNs participate and lead research and/or quality improvement projects to assess the efficacy of services and contribute to the nutrition support body of knowledge, thus promoting and improving evidence-based practice in nutrition support.
      These Standards, along with the Academy/CDR Code of Ethics,
      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.
      answer the questions: Why is an RDN uniquely qualified to provide nutrition support care and services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, efficient, equitable, and quality nutrition support care and service at the competent, proficient, and expert levels?

      Overview

      Nutrition support therapy is defined as providing enteral or parenteral nutrition with therapeutic intent or to treat or prevent malnutrition.
      American Society for Parenteral and Enteral Nutrition (ASPEN) Definition of Terms, Style, and Conventions Used in ASPEN Board of Directors–Approved Documents. ASPEN.
      • Boullata J.
      • Carrera A.L.
      • Harvey L.
      • et al.
      ASPEN Safe practices for enteral nutrition therapy.
      • Guenter P.
      • Boullata J.
      • Ayers P.
      • et al.
      Standardized competencies for parenteral nutrition prescribing: The American Society for Parenteral and Enteral Nutrition Model.
      • Ayers P.
      • Adams S.
      • Boullata J.
      • et al.
      A.S.P.E.N. parenteral nutrition safety consensus recommendations.
      • Guenter P.
      • Worthington P.
      • Ayers P.
      • et al.
      Standardized competencies for parenteral nutrition administration: The ASPEN Model.
      Nutrition support is a therapy used with individuals of all ages, diseases, and conditions. Health care practitioners strive to meet the nutritional requirements of individuals who are unable to meet nutrient needs with oral intake alone, have intestinal failure, and/or are unable to meet hydration needs for a variety of reasons. RDNs, integral members of the nutrition support or interprofessional team,
      American Society for Parenteral and Enteral Nutrition (ASPEN) Definition of Terms, Style, and Conventions Used in ASPEN Board of Directors–Approved Documents. ASPEN.
      provide needed expertise on the identification of risk or presence of malnutrition, macro- and micronutrient requirements, type of nutrition support therapy (eg, enteral or parenteral), and appropriate nutrition support access and route (eg, nasogastric vs nasojejunal or tunneled catheter vs port).
      Enteral nutrition is a delivery system “providing nutrition directly into the gastrointestinal tract via a tube, catheter, or stoma that bypasses the oral cavity.”
      Definition of Terms. Academy of Nutrition and Dietetics.
      ,
      American Society for Parenteral and Enteral Nutrition (ASPEN) Definition of Terms, Style, and Conventions Used in ASPEN Board of Directors–Approved Documents. ASPEN.
      Parenteral nutrition is the intravenous administration of nutrients such as amino acids, carbohydrate, lipid, and added vitamins and minerals delivered via central or peripheral route. Central means parenteral nutrition delivered into a large-diameter vein, usually the superior vena cava adjacent to the right atrium. Peripheral means parenteral nutrition delivered into a peripheral vein, usually of the hand or forearm.”
      Definition of Terms. Academy of Nutrition and Dietetics.
      ,
      American Society for Parenteral and Enteral Nutrition (ASPEN) Definition of Terms, Style, and Conventions Used in ASPEN Board of Directors–Approved Documents. ASPEN.
      An RDN’s practice in nutrition support varies according to practice setting, the number of individuals requiring specialized nutrition support, and role and responsibilities. The primary setting is acute care hospitals (eg, academic, community, and critical access). Populations encompass adults, pediatric and neonatal, surgical, oncology, renal, gastrointestinal, and transplant, among others. In addition, RDNs practicing in nutrition support work in ambulatory/outpatient settings, home care, and alternate site care (ie, long-term acute care, rehabilitation, and skilled/long-term care).
      • Durfee S.M.
      • Adams S.C.
      • Arthur E.
      • et al.
      A.S.P.E.N. standards for nutrition support: Home and alternate site care.
      RDNs practicing in nutrition support therapy may conduct research, teach, consult, and write for peer-reviewed professional publications (solely or in combination with a clinical practice).
      In clinical settings, RDNs in nutrition support evaluate nutrition screening results, conduct nutrition assessments with nutrition-focused physical examinations,

      Mordarski B, Wolff J. Nutrition Focused Physical Exam Pocket Guide, 2nd ed. Academy of Nutrition and Dietetics. Published 2017. Accessed August 9, 2021. https://www.eatrightstore.org/product-type/pocket-guides/nutrition-focused-physical-exam-pocket-guide-second-edition

      ,

      Pediatric Nutrition Focused Physical Exam Pocket Guide. Academy of Nutrition and Dietetics. Published July 9, 2015. Accessed August 9, 2021. https://www.eatrightstore.org/product-type/pocket-guides/pediatric-nutrition-focused-physical-exam-pocket-guide

      confer with interprofessional team members, determine plan(s) of care, and provide ongoing monitoring and adjustments to the plan of care. With privileging
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      ,
      • Peterson S.
      • Dobak S.
      • Phillips W.
      • et al.
      Enteral and parenteral order writing survey—A Collaborative evaluation between the Academy of Nutrition and Dietetics’ Dietitians in Nutrition Support Dietetics Practice Group and the American Society for Parenteral and Enteral Nutrition (ASPEN) Dietetics Practice Section.
      and/or organization-approved policies and protocols, RDNs place enteral feeding tubes
      • Powers J.
      • Brown B.
      • Lyman B.
      • et al.
      Development of a competency model for placement and verification of nasogastric and nasoenteric feeding tubes for adult hospitalized patients.
      ,
      • Roberts S.
      • Brody R.
      • Rawal S.
      • Byham-Gray L.
      Volume-based vs rate-based enteral nutrition in the intensive care unit: Impact on nutrition delivery and glycemic control.
      and initiate, implement, and/or adjust protocol- or physician-order-driven EN- or PN-related plans.
      There are a variety of patients/clients seen by RDNs in nutrition support who span all ages (including neonatal, pediatric,
      Preterm Infant (VLBW) Enteral Nutrition Guideline. Evidence Analysis Library.
      ,
      • Corkins M.
      • Griggs K.
      • Groh-Wargo S.
      • et al.
      Standards for nutrition support: Pediatric hospitalized patients.
      and adult
      • Ukleja A.
      • Gilbert K.
      • Mogensen K.M.
      • et al.
      Standards for nutrition support: Adult hospitalized patients.
      ) and diseases/conditions. Therefore, a person-centered approach is critical to care. RDNs must have the knowledge, skill, and experience in the application of principles and guidelines in delivering nutrition support, along with general knowledge of all potential comorbidities of a patient/client, in order to appropriately address and provide quality nutrition care and services or know when to confer with or refer to another provider.
      Since patients/clients requiring nutrition support therapy present with varied and complex treatment issues, the RDN must consider the ethical implications
      • Neklin M.B.
      How do I know whether it is an ethical issue? Helping registered dietitian nutritionists identify ethical issues in practice.
      • Schwartz D.B.
      • Armanios N.
      • Monturo C.
      • et al.
      Clinical ethics and nutrition support practice: Implications for practice change and curriculum development.
      • Schwartz D.B.
      Integrating patient-centered care and clinical ethics into nutrition practice.
      of nutrition and hydration,
      • Schwartz D.B.
      • Posthauer M.E.
      • O’Sullivan Maillet J.
      Advancing nutrition and dietetics practice: Dealing with ethical issues of nutrition and hydration.
      ,
      • Schwartz D.B.
      • Barrocas A.
      • et al.
      Ethical aspects of artifically administered nutrition and hydration: An ASPEN Position Paper.
      particularly in certain populations, such as those with dementia
      • Schwartz D.B.
      Enteral nutrition and dementia integrating ethics.
      or receiving palliative
      • Boyce B.
      An ethical perspective on palliative care.
      or end-of-life care. Care decisions need to reflect the wishes of the patient/client and/or family/surrogate decision-maker, consistent with an advanced directive that may be in place.
      The RDN practicing in nutrition support collaborates with the interprofessional team that includes multiple disciplines according to the specific needs of the patient/client. Core nutrition support team
      American Society for Parenteral and Enteral Nutrition (ASPEN) Definition of Terms, Style, and Conventions Used in ASPEN Board of Directors–Approved Documents. ASPEN.
      members, in addition to the RDN, include a physician(s), pharmacist, and nurse. Other professionals, such as physician assistant, nurse practitioner, respiratory therapist, speech language pathologist, and social worker, may be included in the team to meet the care goals and outcomes. An interprofessional approach has been shown to enhance quality of care, improve patient safety and outcomes,
      • Guenter P.
      • Boullata J.
      • Ayers P.
      • et al.
      Standardized competencies for parenteral nutrition prescribing: The American Society for Parenteral and Enteral Nutrition Model.
      and reduce health care costs.
      • Mistiaen P.
      • Van den Heede K.
      Nutrition support teams: A systematic review.
      Within the interprofessional team, the RDN is a key resource on medical nutrition therapy and various aspects of nutrition support therapy. RDNs may also collaborate with their information technology teams to advance personalized nutrition efforts.
      • Rozga M.
      • Latulippe M.E.
      • Steiber A.
      Advancements in personalized nutrition technologies: Guiding principles for registered dietitian nutritionists.
      • Vanek V.W.
      • Ayers P.
      • Kraft M.
      • Poehls J.M.
      • Turner P.
      • Van Way III, C.
      A call to action for optimizing the electronic health record in the parenteral nutrition workflow.
      • Kight C.E.
      • Bouche J.M.
      • Curry A.
      • Wilk D.
      • Wootton A.
      Consensus recommendations for optimizing electronic health records for nutrition care.
      Personalized nutrition refers to the use of individual measurable data to affect nutritional status or outcomes, such as continuous glucose monitoring or indirect calorimetry.
      • Mistiaen P.
      • Van den Heede K.
      Nutrition support teams: A systematic review.
      RDNs may also collaborate with their information technology team to enhance electronic health record workflow and functionality and improve nutrition support safety.
      • Vanek V.W.
      • Ayers P.
      • Kraft M.
      • Poehls J.M.
      • Turner P.
      • Van Way III, C.
      A call to action for optimizing the electronic health record in the parenteral nutrition workflow.
      ,
      • Kight C.E.
      • Bouche J.M.
      • Curry A.
      • Wilk D.
      • Wootton A.
      Consensus recommendations for optimizing electronic health records for nutrition care.
      Both the Academy
      Evidence Analysis Library
      Academy of Nutrition and Dietetics.
      and ASPEN
      Clinical Guidelines. American Society for Parenteral and Enteral Nutrition.
      have evidence-based practice guidelines and position papers related to nutrition support to help guide RDNs in nutrition support practice. These guidelines cover a variety of topics, including malnutrition in older adults,
      Malnutrition in Older Adults. Evidence Analysis Library. Academy of Nutrition and Dietetics.
      selection and care of central venous access devices for adult home parenteral nutrition administration,
      • Kovacevich D.S.
      • Corrigan M.
      • Ross V.M.
      • McKeever L.
      • Hall A.M.
      • Brauschweig C.
      American Society for Parenteral and Enteral Nutrition guidelines for the selection and care of central venous access devices for adult home parenteral nutrition administration.
      nutrition support in the pediatric critically ill patient,
      • Mehta N.M.
      • Skillman H.E.
      • Irving S.Y.
      • et al.
      Guidelines for the provision and assessment of nutrition support therapy in the pediatric critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition.
      and nutrition support in the adult critically ill patient,
      • McClave S.A.
      • Taylor B.E.
      • Martindale R.G.
      • et al.
      Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient.
      use of visceral protein markers
      • Evans D.C.
      • Corkins M.R.
      • Malone A.
      • et al.
      The use of visceral proteins and nutrition markers: An ASPEN position paper.
      , among others. ASPEN also publishes discipline-based standards for nurses,
      • DiMaria-Ghalili R.A.
      • Gilbert K.
      • Lord L.
      • et al.
      Standards of nutrition care practice and professional performance for nutrition support and generalist nurses.
      pharmacists,
      • Tucker A.
      • Ybarra J.
      • Bingham A.
      • et al.
      American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) standards of practice for nutrition support pharmacists.
      and physicians.
      • Mascarenhas M.R.
      • August D.A.
      • DeLegge M.H.
      • et al.
      Standards of practice for nutrition support physicians.
      Other resources for RDNs in nutrition support can be found in Figure 4.
      The DNS DPG
      A Dietetic Practice Group of the Academy of Nutrition and Dietetics
      Dietitians in Nutrition Support.
      and ASPEN
      Leading the Science and Practice of Clinical Nutrition. American Society for Parenteral and Enteral Nutrition.
      provide an abundance of information and resources for RDNs in nutrition support. The DNS DPG offers resources such as the Support Line newsletter, webinars, symposium, videos, toolkits, mentorship program, podcast recordings, and an online forum. ASPEN resources include webinars, an eLearning Center, an online community, conference, books, journals (Nutrition in Clinical Practice and Journal of Parenteral and Enteral Nutrition), and a Malnutrition Solution Center. The DNS DPG and ASPEN offer volunteer opportunities that promote development of professional relationships.

      Academy and ASPEN Revised 2021 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Nutrition Support

      An RDN can use the Academy and ASPEN Revised 2021 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Nutrition Support (see Figures 1 and 2, available at www.jandonline.org or https://onlinelibrary.wiley.com/journal/19412452, and Figure 3) to:
      • identify the competencies needed to provide nutrition support care and services;
      • self-evaluate whether they have the appropriate knowledge, skills, and judgment to provide safe, effective, equitable, and quality nutrition support care and service for their level of practice;
      • identify the areas in which additional knowledge, skills, and experience are needed to practice at the competent, proficient, or expert level of nutrition support practice;
      • provide a foundation for public and professional accountability in nutrition support care and services;
      • support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of nutrition support services and resources;
      • enhance professional identity and skill in communicating the nature of nutrition support care and services;
      • guide the development of nutrition support-related education and continuing education programs, job descriptions, practice guidelines, protocols, clinical models, competence evaluation tools, and career pathways; and
      • assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in nutrition support, and the understanding of the full scope of this focus area of practice.

      Application to Practice

      All RDNs, even those with significant experience in other practice areas, must begin at the competent level when practicing in a new setting or new focus area of practice. At the competent level, an RDN in nutrition support is learning the principles that underpin this focus area and is developing knowledge, skills, judgment, and gaining experience for safe and effective nutrition support practice. This RDN, who may be new to the profession or may be an experienced RDN, has a breadth of knowledge in nutrition and dietetics and may have proficient or expert knowledge/practice in another focus area. However, the RDN new to the focus area of nutrition support must accept the challenge of becoming familiar with the body of knowledge, required clinical judgment skills, practice guidelines, and available resources to support and ensure quality nutrition support–related nutrition and dietetics practice. Specific to nutrition support, RDNs at the competent level are able to independently complete nutrition assessments for patients with a variety of co-morbid conditions, calculate macronutrient needs to promote or sustain recovery, and recommend nutrition support regimens according to best practice and consistent with individualized care plans.
      At the proficient level, an RDN has developed a more in-depth understanding of nutrition support practice and is more skilled at adapting and applying evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice according to unique situations. The RDN at the proficient level may possess a specialist credential(s). RDNs in nutrition support practicing at the proficient level may have obtained privileges or receive physician-delegated orders to order and manage nutrition support therapies, and are able to manage a higher-volume, more complex patient load compared to the RDN at the competent level. Experienced RDNs in nutrition support may also serve as a mentor or preceptor to nutrition and dietetics students/interns and/or a mentor to competent-level practitioners on management of patients requiring nutrition support therapies.
      At the expert level, the RDN thinks critically about nutrition support, demonstrates a more intuitive understanding of the practice area, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of education, experience, and critical thinking. Essentially, practice at the expert level requires the application of composite nutrition and dietetics knowledge, with practitioners drawing not only on their practice experience, but also on the experience of the nutrition support RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of nutrition support within a contextual whole, are fluid and flexible, and have considerable autonomy in practice. They not only develop and implement nutrition support services; they also manage, drive, and direct clinical care; conduct and collaborate in research and advocacy; work for pharmaceutical companies; accept organization leadership roles; engage in scholarly work; guide interprofessional teams; and lead the advancement of nutrition support practice. RDNs in nutrition support practicing at the expert practitioner level are considered experts in the field and incorporate, as appropriate and within state regulations and organizational policies, skills such as insertion of nasoenteric feeding tubes,
      • Powers J.
      • Brown B.
      • Lyman B.
      • et al.
      Development of a competency model for placement and verification of nasogastric and nasoenteric feeding tubes for adult hospitalized patients.
      ,
      • Brown B.
      • Hoffman S.R.
      • Johnson S.J.
      • Nielsen W.R.
      • Greenwaldt H.J.
      Developing and maintaining an RDN-led bedside feeding tube placement program.
      ,
      • Rollins C.
      Blind bedside placement of postpyloric feeding tubes by registered dietitians: Success rates, outcomes, and cost effectiveness.
      and EN and PN order writing.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      ,
      • Peterson S.
      • Dobak S.
      • Phillips W.
      • et al.
      Enteral and parenteral order writing survey—A Collaborative evaluation between the Academy of Nutrition and Dietetics’ Dietitians in Nutrition Support Dietetics Practice Group and the American Society for Parenteral and Enteral Nutrition (ASPEN) Dietetics Practice Section.
      RDNs with extensive experience in the use of nutrition support therapy, often with the CNSC, are leaders in the intensive care units or other settings in which nutrition support is administered. Nutrition care is person-centered and proactive in identifying and addressing needs through the effective application of oral, enteral, and/or parenteral nutrition. The expert-level RDN may also be serving as team coordinator or manager and/or leading an interprofessional team effort to measure and track outcomes data related to malnutrition
      • McCauley S.M.
      • Barrocas A.
      • Malone A.
      Malnutrition quality improvement initiative yields value for interdisciplinary patient care and clinical nutrition practice.
      and other nutrition-related quality measures.
      Indicators for the SOP and SOPP for RDNs in Nutrition Support are measurable action statements that illustrate how each standard can be applied in practice (Figures 1 [SOP] and 2 [SOPP], available at www.jandonline.org and https://onlinelibrary.wiley.com/journal/19412452). Within the SOP and SOPP for RDNs in Nutrition Support, an “X" in the competent column indicates that an RDN who is caring for patients/clients is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent-level RDN in nutrition support could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility to provide nutrition support care for patients/clients. Examples of patients/clients evaluated by a competent-level RDN include those with malnutrition,
      • Khan M.
      • Hui K.
      • McCauley S.M.
      What Is a registered dietitian nutritionist’s role in addressing malnutrition?.
      • Skipper A.
      • Coltman A.
      • Tomesko J.
      • Piemonte T.A.
      • Handu D.
      • Cheng F.W.
      Adult malnutrition (undernutrition) screening: An Evidence Analysis Center systematic review.
      • White J.V.
      • Guenter P.
      • Jensen G.
      • et al.
      Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition).
      • Becker P.
      • Nieman Carney L.
      • Corkins M.R.
      • et al.
      Consensus statement: Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of pediatric malnutrition (undernutrition).
      • Skipper A.
      • Coltman A.
      • Tomesko J.
      • Piemonte T.A.
      • Handu D.
      • Cheng F.W.
      Position of the Academy of Nutrition and Dietetics: Malnutrition (undernutrition) screening tools for all adults.
      gastrointestinal disorders (eg, inflammatory bowel disease), cystic fibrosis,

      McDonald CM, Alvarez JA, Bailey J, Padula L, Porco K, Rozga M. Academy of Nutrition and Dietetics: 2020 Cystic fibrosis Evidence Analysis Center evidence-based nutrition practice guideline [published online ahead of print June 19, 2020]. J Acad Nutr Diet. https://doi.org/10.1016/j.jand.2020.03.015

      and dysphagia.
      • Marcason W.
      What is the International Dysphagia Diet Standardization Initiative?.
      Collaborating for consistency: Best practices for implementing the IDDSI framework. Academy of Nutrition and Dietetics.
      • Dobak S.
      • Kelly D.
      Tough pill to swallow: Postextubation dysphagia and nutrition impact in the intensive care unit.
      An “X" in the proficient column indicates that an RDN who performs at this level has a deeper understanding of nutrition support therapy and has the ability to modify or guide therapy to meet the needs of patients/clients in various situations (eg, patients/clients with diabetes,
      • Davidson P.
      • Ross T.
      • Castor C.
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Diabetes Care.
      renal conditions,
      • Pace R.C.
      • Kirk J.
      Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition.
      electrolyte disturbances, acute pulmonary failure on a ventilator, complicated wounds, or neonates on enteral nutrition).
      Preterm Infant (VLBW) Enteral Nutrition Guideline. Evidence Analysis Library.
      ,
      • Corkins M.
      • Griggs K.
      • Groh-Wargo S.
      • et al.
      Standards for nutrition support: Pediatric hospitalized patients.
      ,
      • Nevin-Folino N.
      • Ogata B.N.
      • Charney P.J.
      • et al.
      Academy of Nutrition and Dietetics: Revised 2015 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Pediatric Nutrition.
      An “X" in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of nutrition support therapy and a highly developed range of skills and judgments acquired through a combination of experience and education. The expert RDN builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, vision, and credentials.
      Standards and indicators presented in Figure 1 and Figure 2 (available at www.jandonline.org and at https://onlinelibrary.wiley.com/journal/19412452) in boldface type originate from the Academy’s 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.
      and should apply to RDNs in all 3 levels. Additional indicators not in boldface type developed for this focus area are identified as applicable to all levels of practice. Where an “X" is placed in all 3 levels of practice, it is understood that all RDNs in nutrition support are accountable for practice within each of these indicators. However, the depth with which an RDN performs each activity will increase as the individual moves beyond the competent level. Several levels of practice are considered in this document; thus, taking a holistic view of the SOP and SOPP for RDNs in Nutrition Support is warranted. It is the totality of individual practice that defines a practitioner’s level of practice and not any one indicator or standard.
      RDNs should review the SOP and SOPP in Nutrition Support at determined intervals to evaluate their individual focus area knowledge, skill, and competence. Consistent self-evaluation is important because it helps identify opportunities to improve and enhance practice and professional performance and set goals for professional development. This self-appraisal also enables nutrition support RDNs to better use these Standards as part of the Professional Development Portfolio recertification process,
      • Weddle D.O.
      • Himburg S.P.
      • Collins N.
      • Lewis R.
      The professional development portfolio process: Setting goals for credentialing.
      which 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 5-year recertification cycle 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 the Competency Plan Builder
      Competency plan builder instructions. Commission on Dietetic Registration.
      (step 1), which is a digital tool that assists practitioners in creating a continuing education learning plan. It helps identify focus areas during each 5-year recertification cycle for verified CDR-credentialed nutrition and dietetics practitioners. The Activity Log (step 2) is used to log and document continuing professional education during the 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 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.
      RDNs are encouraged to pursue additional knowledge, skills, and training, 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 by state law, where applicable. RDNs are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience.
      • Gates G.R.
      • Amaya L.
      Ethics opinion: Registered dietitian nutritionists and nutrition and dietetics technicians, registered are ethically obligated to maintain personal competence in practice.
      RDNs should collaborate with other RDNs in nutrition support to gain and provide learning opportunities, promote consistency in practice, and perpetuate alliances in continuous quality improvement and research. See Figure 5 for role examples of how RDNs in different roles, at different levels of practice, can use the SOP and SOPP for RDNs in Nutrition Support.
      Figure 5Role examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Nutrition Support.
      RoleExamples of use of SOP and SOPP documents by RDNs in different practice roles
      For each role, the RDN updates their professional development plan to include applicable essential practice competencies for nutrition support care and services.
      Clinical practitioner, acute care setting–adult and pediatricAn registered dietitian nutritionist (RDN) providing coverage on a general medical unit will now also be providing care to patients in the medical intensive care unit (ICU). Working with an experienced colleague when needed, the RDN has managed short-term nutrition support therapy for non-ICU patients but recognizes more in-depth knowledge and skills are needed when caring for critically ill patients in an ICU setting. The RDN reviews the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) in Nutrition Support to evaluate level of practice and competence. The RDN reviews the nutrition support-related practice guidelines and seeks mentoring from an experienced nutrition support RDN who is ideally a Certified Nutrition Support Clinician (CNSC) to discuss approach to care, decision-making process for determining enteral nutrition (EN) vs parenteral nutrition (PN), and for monitoring and adjusting nutrition care plan. The RDN identifies continuing education opportunities to pursue to enhance skills and to help decide whether working toward eligibility for the CNSC certification is a career goal.
      Clinical practitioner, home care and alternate-site careAn RDN with the CNSC certification working in nutrition support in an acute care hospital decides to transition to a new opportunity with a home infusion company providing nutrition support services to individuals of all ages in their homes or in an acute rehabilitation, skilled, or long-term care facility. The RDN reviews the SOP and SOPP in Nutrition Support and other focus areas (eg, Pediatric Nutrition, Nephrology Nutrition, Post-Acute and Long-Term Care [PALTC]), position description and scope of work to determine whether any new/enhanced knowledge or skills are needed. The company recently implemented telehealth within its service lines to facilitate communications with health care providers, clients/residents, and facilities using the company’s services. The RDN pursues resources identified in the SOP and SOPP articles and continuing education opportunities, including effective use of telehealth to enhance skills in this delivery method.
      Clinical practitioner, PALTCAn RDN working in a skilled nursing and long-term care facility observes an increase in the number of new residents who require EN. The RDN refers to the SOP and SOPP in Nutrition Support in addition to the SOP and SOPP in PALTC to enhance knowledge and skills to guide assessment and plan of care decision making for these individuals. The RDN reviews the resources identified in the SOP and SOPP articles and indicators to increase knowledge and identify areas for continuing education. When applicable, the RDN contacts an RDN colleague at the community hospital, who provides care for patients receiving nutrition support therapy to gain ideas for care plans, the most appropriate enteral nutrition formula on the facility’s formulary, determining supplemental water and vitamin/mineral supplementation; and other types of adjustments that may be needed to support a resident’s nutritional needs consistent with their wishes.
      Manager, nutrition servicesA manager who oversees RDNs whose responsibilities include providing nutrition support therapy to individuals with a variety of medical conditions considers the SOP and SOPP in Nutrition Support when determining expertise at the program level, position descriptions, career ladders, work assignments, and when evaluating competency and RDN staff needs for additional knowledge and/or skills in nutrition support therapy. The manager recognizes the SOP and SOPP in Nutrition Support along with other applicable focus area standards (eg, pediatric nutrition, nephrology nutrition, diabetes care) as important tools for staff to use to assess their knowledge, skills, and competencies; to identify personal performance plans; and to guide quality improvement data collection and evaluation to optimize patient/client outcomes.
      Community nutrition practitioner, public health practitionerAn RDN working in a WIC
      WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
      clinic notices an increase in the number of clients with specialized infant formula orders who receive the formula via tube feedings. Recognizing the need for and desiring more knowledge about enteral nutrition in this population, the RDN uses the SOP and SOPP in Nutrition Support and SOP and SOPP in Pediatric Nutrition to evaluate their current knowledge and assessment skills and seeks out continuing-education opportunities. The RDN identifies an experienced RDN within the local pediatric hospital/outpatient facility who is willing to provide mentoring and guidance on complex cases that are beyond the RDN’s current level of experience and competence.
      Quality improvement practitionerAn RDN working on their organization’s quality improvement team is actively working to reduce the incidence of malnutrition in patients/clients receiving nutrition support. The RDN uses the SOP and SOPP in Nutrition Support to review relevant resources related to malnutrition and quality improvement and leverages practitioners working at the top of their individual and statutory scope of practice. The RDN reviews the Academy of Nutrition and Dietetics Malnutrition Quality Improvement Initiative (MQii) and ASPEN Malnutrition Solutions Center resources for relevant background, identifies applicable nutrition-related measures, gains buy-in from key stakeholders, and partners with other health care professionals to execute sustainable solutions.
      Faculty and preceptors, nutrition and dietetics education programAn RDN serving as a preceptor in a nutrition support rotation for an accredited nutrition and dietetics education program uses the SOP and SOPP in Nutrition Support to identify appropriate learning activities for students/interns (eg, readings, written assignments, clinical experiences, quality improvement activities, case studies, presentations, and/or discussions with nutrition support practitioners).
      a For each role, the RDN updates their professional development plan to include applicable essential practice competencies for nutrition support care and services.
      b WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
      In some instances, components of the SOP and SOPP for RDNs in Nutrition Support do not specifically differentiate between proficient-level and expert-level practice. In these areas, it remains the consensus of the content experts that the distinctions are subtle and captured in the knowledge, experience, and intuition demonstrated in the context of practice at the expert level, which combines dimensions of understanding, performance, and value as an integrated whole.
      • Chambers D.W.
      • Gilmore C.J.
      • Maillet J.O.
      • Mitchell B.E.
      Another look at competency-based education in dietetics.
      A wealth of knowledge is embedded in the experience, discernment, and practice of expert-level RDN practitioners. The experienced practitioner observes events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. The knowledge and skills acquired through practice will continually expand and mature. The SOP and SOPP indicators are refined with each review of these Standards as expert-level RDNs systematically record and document their experiences, often through use of exemplars. Exemplary actions of individual nutrition support RDNs in practice settings and professional activities that enhance patient/client/population care and/or services, can be used to illustrate outstanding practice models (eg, DNS Distinguished Practice Award,
      Awards
      Dietitians in Nutrition Support Dietetic Practice Group.
      ASPEN Distinguished Nutrition Support Dietitian: Advanced Clinical Practice Award,
      ASPEN Awards
      American Society for Parenteral and Enteral Nutrition.
      ASPEN Distinguished Nutrition Support Dietitian Service Award,
      ASPEN Awards
      American Society for Parenteral and Enteral Nutrition.
      Fellow of ASPEN,
      ASPEN Awards
      American Society for Parenteral and Enteral Nutrition.
      and Fellow of the Academy).

      Future Directions

      The SOP and SOPP for RDNs in Nutrition Support are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, changes to dietetics education standards, regulatory changes, and outcomes of practice audits. Continued clarity and differentiation of the 3 practice levels in support of safe, effective, equitable, and quality practice in nutrition support remains an expectation of each revision to serve tomorrow's practitioners and their patients, clients, and customers.
      To enhance competitiveness in today’s health care environment, RDNs may need to broaden their skill set with additional education (eg, master’s in public health, doctorate in clinical nutrition) and/or credentials (eg, CNSC, CSPCC, and/or RDN-AP) consistent with personal interests and skills needed to address patient/client population needs and preferences and organization objectives. Achieving certification or other credentials is an assured way to demonstrate RDNs are equipped to meet their next challenge, and to expand options for future opportunities. RDNs in nutrition support also have the opportunity to strengthen the role and responsibilities of the profession through promotion of clinical privileging for ordering therapeutic diets and nutrition-related services, including nutrition support therapies, when consistent with state law and health care regulations. Nutrition support RDNs can advance nutrition and dietetics practice by assisting with measurement and reporting of patient-related outcomes; increasing promotion and use of resources related to telehealth
      • Mehta P.
      • Stahl M.G.
      • Germone M.M.
      • et al.
      Telehealth and nutrition support during the COVID-19 pandemic.
      ,; placing feeding tubes
      • Powers J.
      • Brown B.
      • Lyman B.
      • et al.
      Development of a competency model for placement and verification of nasogastric and nasoenteric feeding tubes for adult hospitalized patients.
      ,
      • Brown B.
      • Hoffman S.R.
      • Johnson S.J.
      • Nielsen W.R.
      • Greenwaldt H.J.
      Developing and maintaining an RDN-led bedside feeding tube placement program.
      ,
      • Rollins C.
      Blind bedside placement of postpyloric feeding tubes by registered dietitians: Success rates, outcomes, and cost effectiveness.
      ; becoming trained on new technologies, such as bedside ultrasound to assess muscle changes
      • Bury C.
      • DeChicco R.
      • Nowak D.
      • et al.
      Use of bedside ultrasound to assess muscle changes in the critically ill surgical patient.
      ; leading nutrition support clinics to assess adequacy and tolerance of nutrition support therapies

      Hall B, Englehart M, Blaseg K, Wessel K, Stanislaw P, Evans D. Implementation of dietitian-led enteral nutrition support clinic results in quality improvement, reduced readmissions and cost savings. Nutr Clin Pract. 2014;29(5):649-655.

      ; providing education; demonstrating leadership in emergency planning for natural disasters, product shortages; and using approved care protocols to assess, monitor, maintain, and troubleshoot enteral access devices.

      Summary

      RDNs face complex situations every day. Addressing the unique needs of each situation and applying standards appropriately is essential to providing safe, timely, person-centered quality care and service. All RDNs are advised to conduct their practice based on the most recent edition of the Code of Ethics for the Nutrition and Dietetics Profession, the Scope of Practice for RDNs, and the SOP in Nutrition Care and SOPP for RDNs, along with applicable federal and state regulations and facility accreditation standards. The SOP and SOPP for RDNs in Nutrition Support are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by RDNs in nutrition support daily practice who provide care to individuals to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, equitable, and quality nutrition and dietetics care and services. These standards also serve as a professional resource for self-evaluation and professional development for RDNs specializing in nutrition support practice. Just as a professional’s self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress and will be reviewed and updated every 7 years.
      Current and future initiatives of the Academy and ASPEN, as well as advances in nutrition support care and services, will provide information to use in future updates and in further clarifying and documenting the specific roles and responsibilities of RDNs at each level of practice. As a quality initiative of the Academy, the DNS DPG, and ASPEN and its Dietetics Practice Section, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.
      These standards have been formulated for use by individuals in self-evaluation, practice advancement, development of practice guidelines and specialist credentials, and as 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 credentialed nutrition and dietetics practitioner. These 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 within the sole authority and discretion of the user.

      Acknowledgements

      Special acknowledgement and thanks to Stephanie Dobak, MS, RD, LDN, CNSC, and Ainsley Malone, MS, RDN, LD, CNSC, FAND, FASPEN, in addition to Brett Baney, MS, RD; Kalli Castille, MS, RDN, LD, FAND; June Greaves, RD, CNSC, CD-N, LD, LDN, LRD; Carol Ireton-Jones, PhD, RDN, LD, CNSC, FASPEN, FAND; Jessica Justice, RD, LDN, CNSC; Steven Plogsted, BS, PharmD, BCNSP, CNSC; Jennifer Sporay, MS, RDN-AP, CSO, LDN, CNSC, FAND; Renee Walker, MS, RDN, LD, CNSC, FASPEN, FAND; and Hailey Wilson, MS, RD, CNSC, who willingly gave their time to review these standards. The authors also give thanks to the Dietitians in Nutrition Support Dietetic Practice Group’s Executive Committee and the American Society for Parenteral and Enteral Nutrition’s Clinical Practice Committee. The authors also extend thanks to all who were instrumental in the process for the revisions of the article. Finally, the authors thank Academy staff, in particular, Carol Gilmore, MS, RDN, LD, FADA, FAND; Dana Buelsing, MS, CAPM; Karen Hui, RDN, LDN; and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, who supported and facilitated the development of these SOP and SOPPs.

      Author Contributions

      Each author contributed to drafting and editing the components of the article (eg, article text and figures) and reviewed all drafts of the manuscript.

      Supplementary Materials

      Figure 1Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Nutrition Support. 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 Registered Dietitian Nutritionists in Nutrition Support

      Standard 1: Nutrition Assessment

      The registered dietitian nutritionist (RDN) uses accurate and relevant data and information to identify nutrition-related problems.

      Rationale:

      Nutrition screening is the preliminary step to identify individuals who require a nutrition assessment performed by an RDN. Nutrition assessment is a systematic process of obtaining and interpreting data in order to make decisions about the nature and cause of nutrition-related problems and provides the foundation for nutrition diagnosis. It is an ongoing, dynamic process that involves not only initial data collection, but also reassessment and analysis of patient/client or community needs. Nutrition assessment is conducted using validated tools based in evidence, the 5 domains of nutrition assessment, and comparative standards. Nutrition assessment may be performed via in-person, or facility/practitioner assessment application, or Health Insurance Portability and Accountability Act–compliant video conferencing telehealth platform.
      Indicators for Standard 1: Nutrition Assessment
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Patient/client/population history: Assesses current and past information related to personal, medical, family, and psychosocial/social historyXXX
      1.1AReviews admission nutrition screening data or screens for nutrition risk (eg, malnutrition, nutrient deficits, food security) using evidence-based screening tools for the setting and/or population (adult or pediatric)XXX
      1.1BEvaluates health status and disease conditions(s) history for application to nutrition care, including:
      • medical history, etiology of present conditions(s), and access to health care
      • risk factors for medical conditions (eg, family medical history, diabetes, hypertension, cardiovascular disease, chronic kidney disease)
      • age-related nutrition issues and comorbidities (eg, diabetes, obesity, hypertension, congestive heart failure, dyslipidemia, depression, gastrointestinal diseases, ability to chew/swallow foods and/or fluids)
      • evidence or documentation of malnutrition (eg, weight change, abnormal rate of growth and weight gain, prolonged poor intake, abnormal laboratory trends, previous physical assessment findings)
      • history of tobacco use (eg, cigarettes, e-cigarettes, or smokeless tobacco); and mental health, addiction, or substance use disorder
      • social determinants of health (eg, access to health care, community resources; availability of housing and transportation; social support; and economic stability)
      XXX
      1.1CAssesses the effect of disease on ingestion, digestion, absorption, and utilization of nutrients, taking into consideration clinical factors that may cause interference (mechanical, physiological, or psychological); seeks assistance if neededXXX
      1.1DEvaluates psychosocial factors or issues; social and/or cognitive impairment support; depression/anxiety; and disordered eatingXXX
      1.1EAssesses history of mental health disorders (eg, depression, bipolar disorder, anxiety, attention deficit hyperactivity disorder); seeks assistance if neededXX
      1.1FAssesses history of problems with ingestion, digestion, absorption, and metabolism of macronutrients and micronutrients resulting from comorbid conditions or complications (eg, diabetes, bariatric surgery, end-stage kidney disease, swallowing disorders, malnutrition)XX
      1.1GIdentifies potential nutrition complications related to chronic or acute conditionsXX
      1.1HDistinguishes underlying potential for coexisting disease or nutrition conditions that may be contributing to present nutrition/disease stateX
      1.2Anthropometric assessment: Assesses anthropometric indicators (eg, height, weight, body mass index, waist circumference, arm circumference), comparison to reference data (eg, percentile ranks/z scores), and individual patterns and historyXXX
      1.2AIdentifies age-appropriate reference standards for comparisonXXX
      1.2BIdentifies and considers limitations of reference standards related to age, race, ethnicity, or genderXXX
      1.2CEstimates and modifies anthropometric measurements as appropriate (eg, for amputation(s), paralysis, physical or developmental disabilities, or pregnancy)XXX
      1.2DIdentifies and interprets trends in anthropometric indices taking into consideration cultural diversity (eg, for suboptimal growth and development or overweight/obesity in children, adolescents, and teens); seeks assistance if neededXXX
      1.2EEvaluates body composition using alternative anthropometric assessment methods (eg, mid-arm muscle circumference, creatinine height index)XX
      1.2FEvaluates body composition using available diagnostic results (eg, magnetic resonance imaging scan, ultrasound, CT
      CT = computed tomography.
      scan or DEXA
      DEXA = dual-energy x-ray absorptiometry.
      )
      X
      1.3Biochemical data, medical tests, and procedure assessment: Assesses laboratory profiles (eg, acid–base balance, renal function, endocrine function, inflammatory response, vitamin/mineral profile, lipid profile), and medical tests and procedures (eg, gastrointestinal study, metabolic rate)XXX
      1.3AEvaluates nutrition implications of diagnostic and therapeutic procedures:
      • laboratory data (eg, hyperglycemia, hyper/hypokalemia, dyslipidemia, and other nutrition-related biochemical parameters)
      • blood pressure
      Seeks assistance if needed
      XXX
      1.3BAssesses the need or potential benefit for additional diagnostic tests (eg, abdominal imaging, modified barium swallow study, malabsorption studies) or therapeutic procedures (eg, placement of parenteral or enteral access device suitable for long-term nutrition support therapy, ie, enteral nutrition [EN] or parenteral nutrition [PN])XX
      1.3CEvaluates appropriateness and validity of tests used to evaluate nutrition status and/or effects of nutrition support therapyXX
      1.3C1Identifies physical/biochemical signs and symptoms of nutrition support–related infections (eg, central line infections) or other infections affecting the nutrition care planXX
      1.3C2Distinguishes between alterations in nutritional status that may be a result of the disease process and treatment(s) from those due to nutrient deficiencies; and intervenes appropriately to address the underlying issueXX
      1.3C3Demonstrates understanding of complex invasive hemodynamic monitoring devices that may impact the nutrition care plan (eg, pulmonary artery catheter)X
      1.3DApplies critical thinking and experience to interpret results of tests, procedures, and evaluations; and to identify additional data to consider in assessmentX
      1.4Nutrition-focused physical examination (NFPE) may include visual and physical examination: Obtains and assesses findings from NFPE (eg, indicators of vitamin/mineral deficiency/toxicity, edema, muscle wasting, subcutaneous fat loss, altered body composition, oral health, feeding ability [suck/swallow/breathe], appetite, and affect)XXX
      1.4AUses NFPE that includes, but is not limited to, oral and perioral structures; skin and related structures; alterations in taste, smell, and dentition/chewing abilityXXX
      1.4BAssesses for clinical signs and symptoms of malnutrition (undernutrition) (eg, wasting of fat or muscle; dry, brittle, or thinning hair and nails; sarcopenia and cachexia; and decreased hand-grip strength or other measures of physical functioning related to nutrition)XXX
      1.4CConsiders variations in physical presentation of illness and diseaseXXX
      1.4DEvaluates existing and potential access sites for delivery of EN or PN therapyXX
      1.4ERecognizes, evaluates, and communicates complications of PN and/or EN and/or associated access devices; alerts appropriate patient care staff of findings in a timely mannerXX
      1.4FPerforms, with documented competence, comprehensive NFPE, including abdominal and chest/lung examination when appropriateX
      1.5Food and nutrition-related history assessment (ie, dietary assessment)

      Evaluates the following components:
      1.5AFood and nutrient intake including composition and adequacy, meal and snack patterns, and appropriateness related to food allergies and intolerancesXXX
      1.5A1Assesses fluid intake, appetite, and dietary pattern changes (eg, oral issues, chewing and swallowing, gastrointestinal problems, or comorbid conditions), and any changes for potential impact on disease management and indicators for nutrition support therapyXXX
      1.5A2Assesses food and nutrient intake considering the following:
      • type and distribution of macronutrients and sources of protein
      • adequacy of nutrient intake to maintain energy and nitrogen balance
      • history of food allergies/intolerances (eg, gluten sensitivity or intolerance, lactose intolerance)
      • understanding of dietary modifications superimposed with comorbidities (eg, diabetes, cardiovascular disease, infection, cancer)
      • cultural and/or religious food preferences
      • food access and/or presence of food insecurity
      XXX
      1.5A3Assesses daily fluid needs for health, physical activity, fitness level, environmental conditions, and comorbid conditions (eg, renal or heart failure)XXX
      1.5A4Assesses adequacy of micronutrient and electrolyte (potassium, phosphorus, calcium, sodium) intake provided enterally, comparing with evidence-based nutrition recommendations for individuals across the lifespanXXX
      1.5A5Assesses adequacy of micronutrient and electrolyte (potassium, phosphorus, calcium, sodium) intake provided parenterally, comparing with evidence-based nutrition recommendations for individuals across the lifespanXX
      1.5A6Considers food allergies/intolerances in the provision of PN (eg, allergens as it relates to intravenous fat emulsions or other intravenous components)XX
      1.5A7Evaluates the implications for nutrition support therapy of reported food allergy(ies) and associated diseases or conditions (eg, eosinophilic esophagitis) with EN or PN components (eg, lipid emulsions)X
      1.5BFood and nutrient administration including current and previous diets and diet prescriptions and food modifications, eating environment, and EN and PN administrationXXX
      1.5B1Calculates percent of estimated nutritional needs provided by previously documented oral, medical foods/nutrition supplements, EN and/or PN intakeXXX
      1.5B2Consults with home infusion clinic/company or home care provider regarding oral, EN, PN, and/or hydration prescription, when applicableXXX
      1.5B3Recognizes over- and underfeeding nutrition situations and the associated complicationsXXX
      1.5B4Considers need for EN/PN modifications to correct over- or underfeeding, such as EN infusion rate or PN macronutrient contentXXX
      1.5CMedication and dietary supplement use, including prescription and over-the-counter medications, and integrative and functional medicine productsXXX
      1.5C1Assesses safety, quality, and efficacy of over-the-counter medications and integrative and functional medicine products; evaluates actual or potential drug–nutrient and drug–drug interactions in consultation with pharmacist or other professionals, if indicated, using database resources (eg, Natural Medicines Database; https://naturalmedicines.therapeuticresearch.com/); seeks assistance if neededXXX
      1.5C2Assesses the nutrition implications of overall medication regimen, including adherence, side effects, and medication dose changes/discontinuationXX
      1.5C3Considers the need to add or discontinue medications that may alter nutrition status (eg, propofol, intravenous electrolyte replacements)X
      1.5DKnowledge, beliefs, and attitudes (eg, understanding of nutrition-related concepts, emotions about food/nutrition/health, body image, preoccupation with food and/or weight, readiness to change nutrition- or health-related behaviors, and activities and actions influencing achievement of nutrition-related goals)XXX
      1.5D1Assesses patient/client perceptions of previous nutrition interventionsXXX
      1.5D2Considers patient’s/client’s/advocate’s
      Advocate: An advocate is a person who provides support and/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 Terms13 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation.7)
      ability to understand the risks and benefits of food and beverage choices and/or EN or PN when applicable considering health conditions(s)
      XXX
      1.5D3Evaluates:
      • self-care skills, behaviors, health care knowledge/ beliefs/attitudes from the patient’s/client’s/advocate’s/caregiver's perspective
      • patient’s/client’s/advocate’s ability to identify evidence-based nutrition information among resources found in media and popular literature
      • various influences (eg, language, physical activity, social networks, culture, ethnicity, and religion) that may impact behavior change
      XXX
      1.5D4Accounts for behavioral mediators (or antecedents) related to nutrition support therapy (eg, attitudes, knowledge, intentions, readiness, and willingness to change; perceived social support; outside/caregiver influence)XX
      1.5D5Reviews administration methods and use of equipment for nutrition support therapy, when applicable, in relation to self-care skills, compliance, and behaviorsX
      1.5EFood security defined as factors affecting access to a sufficient quantity of safe, healthful food and water, as well as food-/nutrition-related suppliesXXX
      1.5E1Assesses food and water safety, access, and availability of healthy food/meals:
      • appropriate food preparation resources (eg, financial, food markets/grocery stores, and equipment for safe cooking, serving, and food storage)
      • food environment or access (eg, use of food pantry, meal programs, living situation, transportation)
      • plans for emergency situations/disaster events (eg, availability of appropriate food, water, supply of medications, nutrition supplements, or EN formula and supplies when applicable)
      • availability of family/advocate/caregiver to assist with obtaining/preparing food or home administration of EN or PN, if needed
      XXX
      1.5E2Evaluates ability to adhere to/participate in an appropriate nutrition support therapy regimenXX
      1.5E3Evaluates the need for additional resources to overcome barriersXX
      1.5FPhysical activity, cognitive and physical ability to engage in developmentally appropriate nutrition-related tasks (eg, self-feeding and other activities of daily living [ADLs]), instrumental ADLs (eg, shopping, food preparation), and breastfeedingXXX
      1.5F1Assesses health literacy and numeracy (eg, ability to read, write, and perform calculations)XXX
      1.5F2Identifies factors or events that may impact patient’s/client’s physical and cognitive abilities (eg, hospitalization, amputation, retinopathy, anemia, uremia/inadequate dialysis, change in living situation or caregiver support)XXX
      1.5F3Considers results from validated or commonly accepted developmental, functional, and mental status evaluation tools (eg, Karnofsky Performance Scale, Pediatric Quality of Life inventory ADLs, frailty assessment tools, depression screening tools) that reflect cultural, ethnic, and lifestyle factors in collaboration with the 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, speech language pathologists, and occupational and physical therapists), depending on the needs of the patient/client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team
      XX
      1.5F4Considers changes in cognitive and/or physical functioning that may affect ability to meet nutrition goalsXX
      1.5F5Anticipates future changes in physical functioning that may affect ability to meet nutrition goalsX
      1.5GOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial, and social determinants of health)XXX
      1.5G1Reviews/evaluates quality of life/end-of-life choices, including advanced directives and/or preferences relevant to the nutrition plan of careXXX
      1.5G2Assesses the risk/history of depression, anxiety, cognition difficulties, disordered eating (eg, maladaptive practices related to food intolerances), or substance abuse in relation to current diagnosis(es) and comorbidities, planned treatment, and the impact on nutritional statusXX
      1.5G3Evaluates outcomes and quality of life parameters in patients/clients receiving nutrition support therapyX
      1.6Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, body mass index, and desired growth patterns (eg, Academy EAL,
      Academy EAL = Academy of Nutrition and Dietetics Evidence Analysis Library (www.andeal.org).
      ASPEN,
      ASPEN = American Society for Parenteral and Enteral Nutrition (www.nutritioncare.org).
      NHANES,
      NHANES = National Health and Nutrition Examination Survey (www.cdc.gov/nchs/nhanes/about_nhanes.htm).
      KDOQI
      KDOQI = Kidney Disease Outcomes Quality Initiative (www.andeal.org/topic.cfm?menu=5303&cat=5557).
      )
      XXX
      1.6AIdentifies the most appropriate reference data and/or standards (eg, international, national, state, institutional, and regulatory) based on practice setting and patient-/client-specific factors (eg, age, race, ethnicity, gender, or disease state)XXX
      1.6A1Identifies nutrition support-related reference standards to be included in organization’s/system’s assessment toolsXX
      1.6A2Recognizes and takes the lead in incorporating guidelines from other practice areas (eg, diabetes, renal, pediatrics) into assessment guidelines and practices for care setting in collaboration with interprofessional teamX
      1.6BDetermines energy and nutrient requirements, using appropriate reference standards, considering the individual’s medical status, food/EN and/or PN intake, level of activity, growth rate, growth history, mobility, medications, and other factors affecting energy requirementsXXX
      1.6CRecognizes the effects of nutrition support therapy on the ingestion, digestion, and absorption of nutrientsXX
      1.6DEvaluates implications of data, reference standards, and practice guidelines for impact on nutrition support therapy and managementX
      1.7Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity trainingXXX
      1.7ACompares usual activity level to current age-appropriate physical activity guidelines (https://health.gov/our-work/physical-activity/current-guidelines)XXX
      1.7BEvaluates factors limiting physical activity (eg, visual disturbances, mobility, medication contraindications, medical condition(s), environmental safety)XX
      1.7CConsiders how current and/or proposed physical activity may alter macronutrient requirements and fluid/hydration and revises nutrition support regimen to account for activity levelsXX
      1.8Collects data and reviews data collected and/or documented by the nutrition and dietetics technician, registered (NDTR), other health care practitioner(s), patient/client, or staff for factors that affect nutrition and health statusXXX
      1.8ACommunicates with the interprofessional team, patient/client, advocate or staff regarding collected data that requires additional information and/or clarification before being usedXXX
      1.8BReviews and evaluates data to discern factors that may impact nutrition support deliveryXX
      1.9Uses collected data to identify possible problem areas for determining nutrition diagnosesXXX
      1.9AEvaluates and prioritizes nutrition-related problems (eg, intake, biochemical abnormalities, behavior change, weight change, findings from NFPE or Subjective Global Assessment [SGA], physical activity, medication(s), or treatment adherence) for factors that influence health and nutrition statusXXX
      1.9BEvaluates more complex issues related to food intake and/or EN or PN therapy, and clinical complications (eg, presence of nutrition risk factors or malnutrition and multiple complications) for prioritizing nutrition diagnosesXX
      1.9CEvaluates complex food-, medication-, or treatment-related issues, clinical complications, and current or anticipated treatment options (eg, surgery, withdrawal of treatment, or other medical management adjustments) in prioritizing nutrition problems in collaboration with the interprofessional teamX
      1.10Documents and communicates:
      1.10ADate and time of assessmentXXX
      1.10BPertinent data (eg, medical, social, behavioral)XXX
      1.10CComparison to appropriate standards (eg, macronutrients, micronutrients)XXX
      1.10DPatient/client/population perceptions, values and motivation related to presenting problemsXXX
      1.10EChanges in patient/client/population perceptions, values and motivation related to presenting problemsXXX
      1.10FReason for discharge/discontinuation or referral, if appropriateXXX
      Examples of Outcomes for Standard 1: Nutrition Assessment
      • Appropriate assessment tools and procedures are used in valid and reliable ways
      • Appropriate and pertinent data are collected
      • Effective interviewing methods are used
      • Data are organized and in a meaningful framework that relates to nutrition problems
      • Use of assessment data leads to the determination that a nutrition diagnosis/problem does or does not exist
      • Problems that require consultation with or referral to another provider are recognized
      • Documentation and communication of assessment are complete, relevant, accurate, and timely
      Standard 2: Nutrition Diagnosis

      The registered dietitian nutritionist (RDN) identifies and labels specific nutrition problem(s)/diagnosis(es) that the RDN is responsible for treating.

      Rationale:

      Analysis of the assessment data leads to identification of nutrition problems and a nutrition diagnosis(es), if present. The nutrition diagnosis(es) is the basis for determining outcome goals, selecting appropriate interventions, and monitoring progress. Diagnosing nutrition problems is the responsibility of the RDN.
      Indicators for Standard 2: Nutrition Diagnosis
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Diagnoses nutrition problems based on evaluation of assessment data and identifies supporting concepts (ie, etiology, signs, and symptoms)XXX
      2.1AOrganizes and groups data consisting of physical, clinical, psychosocial, behavioral-environmental, and nutrition assessment findings to determine nutrition diagnosis(es) (eg, significant and adequate information for drawing conclusions)XXX
      2.1BEvaluates findings systematically using critical thinking and experience with the population and nutrition support therapy when formulating the nutrition diagnosis; consults with interprofessional team or more experienced practitioner as neededXXX
      2.1CIdentifies, organizes, and prioritizes comprehensive nutrition problem list considering the following:
      • current diagnosis(es) and medical/surgical history and outcomes to identify etiology(ies)
      • signs and symptoms obtained through NFPE
      • nutrition intake data (food, nutrition supplements, EN and/or PN), clinical condition, and comorbidities (eg, diabetes, chronic kidney disease, chewing/swallowing disorder) or interventions (eg, bariatric surgery)
      XX
      2.1DInvestigates and identifies new etiologies for the nutrition problem(s) based on signs and symptomsXX
      2.1ESystematically compares and contrasts assessment findings in formulating a differential nutrition diagnosis(es)XX
      2.1FAnticipates the multifaceted effects of disease progression on the proposed nutrition diagnosis(es)X
      2.1GIdentifies and recognizes physical/biochemical signs and symptoms of nutrition support–related infections (eg, central line infection) or other infections affecting the nutrition diagnosis(es)X
      2.2Prioritizes the nutrition problem(s)/diagnosis(es) based on severity, safety, patient/client needs and preferences, ethical considerations, likelihood that nutrition intervention/plan of care will influence the problem, discharge/transitions of care needs, and patient/client/advocate perception of importanceXXX
      2.2APrioritizes nutrition diagnosis(es) in order of importance or urgency using evidence-based protocols and guidelines for nutrition supportXXX
      2.2BEvaluates assessment data to prioritize nutrition problems/ diagnosis(es) considering:
      • impact/urgency of the identified problems (eg, risk for refeeding syndrome; persistent inadequate energy or protein intake)
      • complications of comorbid diseases or conditions (eg, diabetes, hypertension, nonhealing wound or pressure injury)
      • patient/client/advocate wishes and perceptions of importance including palliative care
      • life-cycle stage
      • evidence-based protocols and guidelines
      XXX
      2.2CRecognizes nutrition support-related problems in the context of patient/client-centered care, optimizing nutrition support therapy to obtain positive outcomesXX
      2.2DWorks/collaborates with interprofessional team to:
      • verify medical/surgical diagnosis(es) and nutrition diagnosis(es) and to determine priority order of nutrition diagnosis(es)
      • determine goals of care and indications for nutrition support therapy, including utility of implementing or continuing EN or PN at the end of life; seeks assistance from more experienced RDN if needed
      XX
      2.2EGuides interprofessional team discussions to address nutrition needs and plans of care for patients/clients with multiple complex care and/or transition of care issues to achieve positive outcomesX
      2.3Communicates the nutrition diagnosis(es) to patients/clients/advocates, community, family members, or other health care professionals when possible and appropriateXXX
      2.3ACommunicates and confirms the nutrition diagnosis(es) using clinical judgment skills (eg, addresses urgent/critical problem(s), reflects wishes of patient/client/advocate, consistent with medical/treatment care plan)XXX
      2.3BEducates the interprofessional team on the specific nutrition diagnosis(es) (eg, malnutrition)XX
      2.4Documents the nutrition diagnosis(es) using standardized terminology and clear, concise written statement(s) (eg, using Problem [P], Etiology [E], and Signs and Symptoms [S] [PES statement(s)] or Assessment [A], Diagnosis [D], Intervention [I], Monitoring [M], and Evaluation [E] [ADIME statement(s)])XXX
      2.4ADocuments and explains nutrition diagnosis(es) in order of importance and in a manner that clearly describes the patient’s/client’s nutrition status and needsXXX
      2.4BExplains relationship of nutrition diagnosis(es) to need/rationale for nutrition support therapy in communications and documentationXX
      2.4CAnticipates and documents projected modifications of nutrition support therapy based on nutrition diagnosis(es) and/or clinical changes for patients/clients currently receiving EN or PNX
      2.5Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      2.5AUses most current information that may impact nutrition diagnosis(s), revises if needed, and communicates change to interprofessional team, patient/client/advocate/caregiver as appropriate in a timely mannerXXX
      Examples of Outcomes for Standard 2: Nutrition Diagnosis
      • Nutrition Diagnostic Statements accurately describe the nutrition problem of the patient/client and/or community in a clear and concise way
      • Documentation of nutrition diagnosis(es) is relevant, accurate, and timely
      • Documentation of nutrition diagnosis(es) is revised as additional assessment data become available
      Standard 3: Nutrition Intervention/Plan of Care

      The registered dietitian nutritionist (RDN) identifies and implements appropriate, person-centered interventions designed to address nutrition-related problems, behaviors, risk factors, environmental conditions, or aspects of health status for an individual, target group, or the community at large.

      Rationale:

      Nutrition intervention consists of 2 interrelated components—planning and implementation.
      • Planning involves prioritizing the nutrition diagnoses, conferring with the patient/client and others, reviewing practice guidelines, protocols and policies, setting goals, and defining the specific nutrition intervention strategy.
      • Implementation is the action phase that includes carrying out and communicating the intervention/plan of care, continuing data collection, and revising the nutrition intervention/plan of care strategy, as warranted, based on change in condition and/or the patient/client/population response.
      An RDN implements the interventions or assigns components of the nutrition intervention/plan of care to professional, technical, and support staff in accordance with knowledge/skills/judgment, applicable laws and regulations, and organization policies. The RDN collaborates with or refers to other health care professionals and resources. The nutrition intervention/plan of care is ultimately the responsibility of the RDN.
      Indicators for Standard 3: Nutrition Intervention/Plan of Care
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      Plans the Nutrition Intervention/Plan of Care:
      3.1Addresses the nutrition diagnosis(es) by determining and prioritizing appropriate interventions for the plan of careXXX
      Prioritization considerations may include:
      3.1ASeverity of nutrition risk or malnutritionXXX
      3.1BPresence of comorbid diseases/conditionsXXX
      3.1CPatient’s/client’s/advocate’s ability and willingness to implement and adhere to nutrition care planXXX
      3.1DActual or risk of acute complicationsXX
      3.1EAnticipation of delayed/late effects of therapy (eg, metabolic abnormalities, catheter infection)XX
      3.1FAnalysis of risk/benefits of initiating nutrition support therapy for patient nearing end of lifeXX
      3.2Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines (eg, Academy EAL, ASPEN), and best practices (see Figure 4 for resources)XXX
      3.2AApplies critical thinking skills reflecting nutrition support knowledge and experience to develop an intervention plan, using current evidence-based practice guidelines to individualize patient/client careXX
      3.2BRecognizes when it is appropriate and safe to recommend deviation from established nutrition guidelines and protocols in consultation with interprofessional team when indicatedXX
      3.2CSynthesizes multiple evidence-based guidelines to develop an intervention plan for patient/client with multiple medical problems (eg, critical illness combined with obesity, diabetes, and acute kidney injury)X
      3.3Refers to policies and procedures, protocols, and program standardsXXX
      3.4Collaborates with patient/client/advocate/population, caregivers, interprofessional team, and other health care professionalsXXX
      3.4AServes as an integral member of the interprofessional teamXXX
      3.4A1Recognizes specific knowledge and skills of the patient/client and of other providers in developing the plan of careXXX
      3.4A2Serves as a resource to colleagues and the interprofessional team on medical nutrition therapy and developing and managing the nutrition support therapy care planXX
      3.4A3Leads the collaborative process with interprofessional team members and other providers, when applicable, in developing the nutrition support therapy care planX
      3.4A4Teaches clinical practice skills and rationales for nutrition interventions to students, colleagues, and interprofessional team membersX
      3.4BEvaluates pertinent data (eg, results of abdominal x-rays, access device placement [eg, intravenous catheters or feeding tubes]), and collaborates with other interprofessional team members to develop the nutrition support therapy care planXX
      3.4CRecommends and, in consultation with pharmacist, suggests alternative methods, as applicable to the situation, to minimize drug–nutrient interactions related to nutrition support therapyXX
      3.5Works with patient/client/advocate/population and caregivers to identify goals, preferences, discharge/transitions of care needs, plan of care, and expected outcomesXXX
      3.5ADevelops clear and measurable goals, outcomes, and plan(s) with patient/client/advocate through shared decision making and consideration of readiness to change and barriers to successful implementationXXX
      3.5BExplains to patient/client/advocate the risks and benefits of the recommended nutrition support therapy; obtains guidance from more experienced practitioner, if neededXXX
      3.5CDevelops nutrition support care plan and disseminates to patient/client/advocate and/or other health care team members as appropriateXX
      3.6Develops the nutrition prescription and establishes measurable patient-/client-focused goals to be accomplishedXXX
      3.6ADevelops or revises the nutrition prescription based on nutrition assessment or re-assessment and nutrition diagnosis(es), treatment plan, goals, and expected outcomesXXX
      3.6A1Considers the educational needs of the patient/client/ advocate or caregiver, taking into account cultural competency, health literacy, food access, and preparation skills, if applicable to achieve person-centered goalsXXX
      3.6A2Selects nutrition support modalities (ie, oral, EN and/or PN) to meet patient’s/client’s macro- and micronutrient requirementsXXX
      3.6A3Determines fluid requirements and appropriate volume of EN/PN formulationXXX
      3.6A4Determines macronutrient content of EN/PN formulation
      • Protein
      • Carbohydrate
      • Fat
      XXX
      3.6A5Determines micronutrient content of EN/PN formulation
      • Vitamins
      • Minerals
      • Electrolytes
      • Trace elements
      XX
      3.6A6Determines micronutrient supplementation required in addition to micronutrients provided via EN/PN formulationX
      3.6BAnticipates potential complications of nutrition intervention (eg, altered glycemic control, electrolyte abnormalities)XX
      3.6CPlans for transition to alternate mode of nutrition support therapy and/or oral diet, as appropriateXX
      3.6DReviews and determines need for initiation and/or adjustment of pharmacotherapy, considering nutrition, physical activity, growth, medication, blood glucose and other laboratory data, and physical examination (eg, intensification of medication management [adjusting dose/timing], discontinuation of medications based on progression of the disease or macronutrient impact), as part of an interprofessional teamXX
      3.7Defines time and frequency of care including intensity, duration, and follow-upXXX
      3.7ADetermines duration and follow-up of care using evidence-based guidelines (eg, EAL, ASPEN), standards of care, facility policy, patient/client needs, established goals and outcomes, and expected response to intervention(s)XXX
      3.7BDetermines appropriate follow-up based on anticipated tolerance of EN/PN prescription or oral diet adequacy, current condition, and potential changes in care plan (eg, swallow study ordered, or surgery scheduled); seeks assistance if neededXXX
      3.7CProvides or develops guidelines reflecting practice guidelines, organization standards, regulations to orient new and/or entry-level staff (eg, RDNs, nurses, interprofessional team)XX
      3.7DCreates and documents contingency planning based on potential responses to nutrition support therapyX
      3.8Uses standardized terminology for describing interventionsXXX
      3.9Identifies resources and referrals neededXXX
      3.9AIdentifies age-appropriate resources and tools to assist patient/client/advocate with management of nutrition support therapy (eg, mobile apps, community and/or web-based support groups)XXX
      3.9BIdentifies and facilitates referrals to programs and/or providers (eg, social work, gastroenterology, surgeon, physical therapist, speech language pathologist, mental health professional) to assist patient/client/advocate with nutrition support-related issues (eg, financial assistance, in home support services)XXX
      3.9CCoordinates with social work or case management and home infusion nutrition support practitioner to develop transitions of care plan for patient/client who will discharge on home nutrition support (new or continuing on home nutrition support) (eg, insurance coverage, referral to home infusion program, caregiver training, additional resources)XX
      Implements the Nutrition Intervention/Plan of Care:
      3.10Collaborates with colleagues, interprofessional team, and other health care professionalsXXX
      3.10ACollaborates with the medical and/or surgical team to facilitate the nutrition support care planXXX
      3.10A1Offers alternatives and potential solutions to nutrition-related problemsXX
      3.10BCommunicates any revision of the nutrition support care plan with the interprofessional teamXXX
      3.10CReviews ongoing and new data (eg, results of abdominal x-rays, access device placement [eg, intravenous catheter and feeding tube]) and collaborates with other interprofessional team members to revise and implement the nutrition support therapy planXX
      3.10DFacilitates and fosters active communication, learning, partnerships, and collaboration with interprofessional team and others as appropriateXX
      3.10ELeads or directs the interprofessional team and others consistent with role and responsibilitiesX
      3.11Communicates and coordinates the nutrition intervention/plan of careXXX
      3.11AEnsures that patient/client and, as appropriate, family/advocate/caregiver, understand and can articulate goals and other aspects of the plan of careXXX
      3.11BCoordinates the nutrition support therapy intervention with the interprofessional team (eg, confers with peripherally inserted central catheter team regarding central venous access before PN initiation)XX
      3.11CCollaborates with interprofessional team or other health care provider(s) to facilitate coordination of care and awareness of potentially conflicting/problematic treatments (eg, medication-dietary supplement interactions)X
      3.12Initiates the nutrition intervention/plan of careXXX
      3.12AUses approved clinical privileges, physician/non-physician practitioner
      Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.7,8 The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law and organization policies.10,11
      -driven orders (ie, delegated orders), protocols, or other facility-specific processes for order writing or for provision of nutrition-related services consistent with applicable specialized training, competence, medical staff, and/or organizational policy
      XXX
      3.12A1Implements, initiates, or modifies orders for therapeutic diet, nutrition-related pharmacotherapy management, or nutrition-related services (eg, medical foods/nutrition/dietary supplements, food texture modifications, EN and PN, laboratory tests, medications, and education and counseling)XXX
      3.12A1iOrders or recommends:
      • diet order modification to correct over and under macro- and/or micronutrient levels or patient reported food intolerances or allergies
      • menu modifications to address insufficient intake or preferences
      • oral nutrition supplementation
      • changes to EN feeding rate and/or supplemental water, when applicable
      XXX
      3.12A1iiPlaces initial or revised orders for EN regimens (eg, formula, volume per feeding or per day, initial and goal rate and advancement schedule, supplemental water; and modular products [eg, protein, fiber]) when applicableXXX
      3.12A1iiiPlaces initial or revised orders for premixed or compounded PN regimens—peripheral or central line administration (eg, amino acid solution, lipid solution, supplemental vitamins, and trace elements, if indicated) in consultation with pharmacist as neededXX
      3.12A1ivUses results of studies (eg, CT scan, swallow evaluation) or recommends or, with clinical privileges, orders laboratory tests and other procedures to support evaluation and monitoring of the nutrition support therapy regimen(s), including but not limited to:
      • indirect calorimetry
      • bioelectric impedance analysis
      • vitamin/mineral levels
      XX
      3.12A1vCollaborates with the clinical pharmacist to determine alternative products (eg, electrolytes, amino acids, lipids, vitamins, minerals, trace elements) and routes (eg, converting intravenous to enteral types) during periods of product shortagesXX
      3.12A1viPlaces initial or revised orders for fluid therapies or electrolyte replacementsX
      3.12A1viiRecommends in consultation with the interprofessional team, insertion and placement verification of PN access devicesX
      3.12A2Manages nutrition support therapies (eg, formula selection, rate adjustments, addition of designated medications and vitamin/mineral supplements to PN solutions or supplemental water for enteral nutrition)XXX
      3.12A2iReviews patient/client care plan with the interprofessional team at regular intervals to provide safe, effective, and evidence-based nutrition support therapyXXX
      3.12A2iiGenerates appropriate nutrition support therapy care plans with the interprofessional team to meet unique needs of patients/clients with complex, chronic conditionsXX
      3.12A2iiiRecommends, or with clinical privileges, orders laboratory tests and other monitoring methods necessary for evaluating and adjusting the nutrition support regimen as indicated, including but not limited to:
      • indirect calorimetry
      • bioelectrical impedance analysis
      • vitamin/mineral levels
      XX
      3.12A2ivLeads the interprofessional team through an analytical decision-making process in complicated, unpredictable, and dynamic situationsX
      3.12A3Initiates and performs nutrition-related services (eg, bedside swallow screenings, monitoring positioning of nasoenteric feeding tubes, and indirect calorimetry measurements, or other permitted services)XXX
      3.12A3iOversees nutrition staff trained to perform indirect calorimetry measurements when applicable, and interprets results in collaboration with the respiratory therapistXX
      3.12A3iiInserts nasogastric or nasoenteric feeding tubes and/or obtains order for swallow study consistent with specialized training and clinical privileges/delegated ordersX
      3.12A3iiiUses ultrasound to assess body composition consistent with specialized training and clinical privileges/delegated ordersX
      3.12BIdentifies tools for nutrition education to support the intervention/ plan of care that are appropriate to the patient’s/client’s and/or advocate’s/caregiver’s educational needs, learning style, and method of communication; uses interpersonal teaching, training, coaching, counseling, or technological approaches, as appropriateXXX
      3.12CTailors nutrition intervention to the developmental stage and cognitive functioning of the patient/client and makes changes to the intervention as appropriateXX
      3.12DDraws on experiential and evidence-based knowledge about the patient/client population to individualize the strategy for complex and dynamic interventions (eg, complex comorbidities, medical or psychological instability)X
      3.13Assigns activities to NDTR and other professional, technical and support personnel in accordance with qualifications, organizational policies/ protocols, and applicable laws and regulationsXXX
      3.13ASupervises professional, technical and support personnel (eg, direct nutrition-related care provided to patients/clients; in the collection of laboratory data, intake/output records, and intake analysis)XXX
      3.13BTrains qualified support personnel (eg, obtaining data from intake and output forms, completing intake analysis incorporating oral, EN and/or PN as applicable to patient/client)XX
      3.13CDevelops nutrition support–related training modules and evaluation tools for personnel to aid in the effective completion of designated activitiesX
      3.14Continues data collectionXXX
      3.14AAnalyzes data trends to modify plans, if indicated; consults with more experienced practitioner or interprofessional team as neededXXX
      3.14BResponds to clinical data analysis by recommending or ordering relevant tests, and/or adjusting the frequency of existing test orders consistent with clinical privileges/delegated ordersXX
      3.14CAnalyzes data trends to predict future deviations in the nutrition support plan, develops plan modifications as indicated, and communicates to the interprofessional team as neededX
      3.15Documents:
      3.15ADate and timeXXX
      3.15BSpecific and measurable treatment goals and expected outcomesXXX
      3.15CRecommended interventionsXXX
      3.15DPatient/client/advocate/caregiver/community receptivenessXXX
      3.15EReferrals made and resources usedXXX
      3.15FPatient/client/advocate/caregiver/community comprehensionXXX
      3.15GBarriers to changeXXX
      3.15HOther information relevant to providing care and monitoring progress over timeXXX
      3.15IPlans for follow-up and frequency of careXXX
      3.15JRationale for discharge or referral if applicableXXX
      Examples of Outcomes for Standard 3: Nutrition Intervention/Plan of Care
      • Goals and expected outcomes are appropriate and prioritized
      • Patient/client/advocate/population, caregivers, and interprofessional teams collaborate and are involved in developing nutrition intervention/plan of care
      • Appropriate individualized patient-/client-centered nutrition intervention/plan of care, including nutrition prescription, is developed
      • Nutrition intervention/plan of care is delivered, and actions are carried out as intended
      • Discharge planning/transitions of care needs are identified and addressed
      • Documentation of nutrition intervention/plan of care is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and Timed
      Standard 4: Nutrition Monitoring and Evaluation

      The registered dietitian nutritionist (RDN) monitors and evaluates indicators and outcomes data directly related to the nutrition diagnosis, goals, preferences, and intervention strategies to determine the progress made in achieving desired results of nutrition care and whether planned interventions should be continued or revised.

      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. Through monitoring and evaluation, the RDN identifies important measures of change or patient/client/population outcomes relevant to the nutrition diagnosis and nutrition intervention/plan of care; describes how best to measure these outcomes; and intervenes when intervention/plan of care requires revision.
      Indicators for Standard 4: Nutrition Monitoring and Evaluation
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Monitors progress:
      4.1AAssesses patient/client/advocate/population understanding and compliance with nutrition intervention/plan of careXXX
      4.1A1Collaborates with the interprofessional team to ensure patient/client/advocate understanding of the nutrition support therapy prescriptionXXX
      4.1A2Determines whether barriers to understanding are present and impacting the patient’s/client’s/advocate’s/caregiver’s compliance with the nutrition intervention/plan of care; seeks assistance if neededXXX
      4.1A3Reassess patient’s/client’s stage of behavior change and learning style to evaluate need to revise nutrition intervention and plan of careXXX
      4.1A4Evaluates patient’s/client’s ability to adhere to the plan of care during hospitalization and after dischargeXX
      4.1A5Refers patient/client to other providers (eg, social work, mental health) and/or community resources as indicated based on assessment to improve adherence to the plan of careXX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Identifies barriers to implementation of the plan of care when applicableXXX
      4.1B2Verifies that volume or goal rate of EN or composition and rate of PN formula matches the order/prescriptionXXX
      4.1B3Communicates and collaborates with members of the interprofessional team and/or others to verify progress and share observations and concerns such as:
      • barriers to implementation of plan of care
      • unable to reach goal rate (eg, diarrhea, fluid limits)
      XXX
      4.1B4Identifies and pursues strategies to overcome known barriersXX
      4.1B5Evaluates nutrition intervention progress in the face of complex clinical situations (eg, multiple comorbid conditions, post-bariatric surgery, malnutrition inflammatory syndrome, multiple organ failure, transplant)X
      4.2Measures outcomes:
      4.2ASelects the standardized nutrition care measurable outcome indicator(s)XXX
      4.2A1Considers patient/client-centered outcomes (eg, quality of life, physical well-being, anthropometric and laboratory data, and individual’s/advocate’s satisfaction)XXX
      4.2A2Uses multiple data sources to assess progress

      Examples include:
      • adequacy of food and nutrition supplements, when applicable
      • volume and adequacy of EN and/or PN formula, when applicable
      • changes in body weight, composition
      • laboratory and other test results
      • positive/negative effects of pertinent medications and dietary supplements
      • changes in cognitive and functional status
      • changes in skin integrity
      • change in physical activity level
      Seeks assistance if needed
      XXX
      4.2A3Identifies individualized outcomes according to comprehensive review of clinical statusXX
      4.2BIdentifies positive or negative outcomes including impact on potential needs for discharge/transitions of careXXX
      4.2B1Documents progress in meeting desired goals (eg, weight gain or maintenance, improved meal/snack/nutrition supplement intake or tolerance of EN formula, progress toward weaning from EN and/or PN to food, when applicable)XXX
      4.2B2Identifies unintended consequences (eg, continued weight loss, blood glucose variability), or the use of inappropriate methods of achieving goals (eg, medication or dietary supplement erratic use/noncompliance, self-imposed dietary restrictions, personal beliefs)XX
      4.2B3Uses knowledge of the population, experience, and critical thinking in evaluating complex changes in condition(s), impact of interventions, and other factors on achievement of outcomesX
      4.3Evaluates outcomes:
      4.3ACompares monitoring data with nutrition prescription and established goals or reference standardXXX
      4.3A1Completes analysis of the indicators for each problem area using additional monitoring tools, such as:
      • functionality/ADLs
      • respiratory weaning parameters
      • indirect calorimetry measurement and interpretation
      • detailed radiology examinations
      • serial and trended laboratory test results
      XX
      4.3A2Evaluates impact of patient’s/client’s right to self-determination and its effect on the planned interventions and achieving desired health outcomes and/or quality of life in consultation with the interprofessional teamXX
      4.3A3Analyzes the data considering the complexity of problems and correlates one problem to another (eg, using expert clinical judgment skills in the presence of often multiple complex comorbidities)X
      4.3A4Benchmarks individual patient/client data to national, regional, and local data sets (eg, Oley Foundation, National Nosocomial Infection Surveillance System; other applicable reference standards or benchmarking systems)X
      4.3BEvaluates impact of the sum of all interventions on overall patient/client/population health outcomes and goalsXXX
      4.3B1Evaluates the patient's/client's variance from planned outcomes and incorporates findings into future individualized treatment recommendationsXXX
      4.3B2Assesses need for continuation of interventions based on outcomes and clinical data (eg, weight now within normal limits, patient/client alert and desires change to oral diet)XX
      4.3B3Determines cost-to-benefit ratio of current evidence-based interventions/best practices and outcomes when evaluating need for change in patient’s/client’s nutrition support planX
      4.3B4Completes a trending analysis of the indicators and how they correlated with each other to identify patterns, to determine and evaluate the complexity of problems, and influence on patient/client/population health outcomes in collaboration with the interprofessional teamX
      4.3CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.3C1Reviews collected data (eg, NFPE [initial or reassessment], laboratory and diagnostic test results, food/nutrition supplement and/or EN or PN intake, and procedure results [eg, swallow studies, abdominal radiographs] to evaluate therapy outcomes and/or to identify any unanticipated finding[s])XX
      4.3C2Recognizes problems that are beyond the scope of nutrition that are interfering with interventions and achieving desired outcomes; makes referrals or consults with interprofessional team to address issuesXX
      4.3DEvaluates evidence that the nutrition intervention/plan of care is maintaining or influencing a desirable change in the patient/client/population behavior or statusXXX
      4.3D1Evaluates factors (physical, social, cognitive, environmental) that may influence response to nutrition intervention and consults with interprofessional team as neededXXX
      4.3D2Incorporates patient/client-specific evidence from multiple areas (eg, anthropometrics, signs and symptoms of nutrient deficiencies, biochemical data, medication use) to determine the status of established goals and outcomesXX
      4.3D3Initiates interprofessional team or referring practitioner consultation to identify next steps for interventions when indicated for unstable and rapidly changing patient/client statusXX
      4.3D4Analyzes outcome measures to assess overall effectiveness of nutrition intervention/plan of careX
      4.3ESupports conclusions with evidenceXXX
      4.3E1Uses evidence-based standards to evaluate patient/client outcomes (eg, Academy EAL guidelines and/or the Society of Critical Care Medicine/ASPEN Critical Care Guidelines)XXX
      4.4Adjusts nutrition intervention/plan of care strategies, if needed, in collaboration with patient/client/population/advocate/caregiver and interprofessional teamXXX
      4.4AImproves or adjusts intervention/plan of care strategies based upon outcomes data, trends, best practices, and comparative standardsXXX
      4.4A1Modifies intervention strategies as needed (eg, change in health status, transition from EN to oral diet, change in patient/client/advocate preferences or transition to hospice care); seeks assistance if neededXXX
      4.4A2Modifies nutrition support therapy as appropriate to address patient/client needs, new/emerging situation (such as comorbidities and complications), and results of any further testingXX
      4.4A2iTroubleshoots connection(s) issues and collaborates with interprofessional team members to assure appropriate accessXX
      4.4A2iiIdentifies supply issues that hinder safe and timely delivery of nutrition support and intervenes to identify alternative solutions (eg, during vitamin shortages)XX
      4.4A3Integrates interprofessional team input and refines prescribed nutrition intervention/plan of careXX
      4.4A4Anticipates and solves future barriers to delivery of the plan and adjusts nutrition support care plan, as indicatedX
      4.4BImplements the revised nutrition care plan consistent with best practices and impact on patient/client careXXX
      4.4CEnsures communication of nutrition plan of care and transfer of nutrition-related data between care settings (eg, acute care, home health, ambulatory care, and/or long-term care facility) as neededXXX
      4.4DArranges for additional resources and support services (eg, training of direct care providers, collaboration with health care professionals for implementing nutrition intervention/plan of care in patients/clients balancing multiple situations [eg, emergency situations, and/or clinical complications])XX
      4.4ETailors tools and methods to ensure desired outcomes reflect the patient’s/client’s developmental age, social, physical, environmental factors, and nutrition support treatment goalsXX
      4.4FAdjusts in complicated situations by drawing on practice experience, knowledge, clinical judgment, and evidence-based practice about the patient/client population in complicated, unpredictable, and dynamic situations (eg, critical care, eating disorders, wound management, and factors related to comorbid conditions/complications)X
      4.5Documents:
      4.5ADate and timeXXX
      4.5BIndicators measured, results, and the method for obtaining measurementXXX
      4.5CCriteria to which the indicator is compared (eg, nutrition prescription/goal or a reference standard)XXX
      4.5DFactors facilitating or hampering progressXXX
      4.5EOther positive or negative outcomesXXX
      4.5FAdjustments to the nutrition intervention/plan of care, if indicatedXXX
      4.5GFuture plans for nutrition care, nutrition monitoring and evaluation, follow-up, referral, or dischargeXXX
      Examples of Outcomes for Standard 4: Nutrition Monitoring and Evaluation
      • The patient/client/community outcome(s) directly relate to the nutrition diagnosis and the goals established in the nutrition intervention/plan of care. Examples include, but are not limited to:
        • Nutrition outcomes (eg, change in knowledge, behavior, food, or nutrient intake)
        • Clinical and health status outcomes (eg, change in laboratory values, body weight, blood pressure, risk factors, signs and symptoms, clinical status, infections, complications, morbidity, and mortality)
        • Patient/client/population-centered outcomes (eg, quality of life, satisfaction, self-efficacy, self-management, functional ability)
        • Health care utilization and cost effectiveness outcomes (eg, change in medication, special procedures, planned/unplanned clinic visits, preventable hospital admissions, length of hospitalizations, prevented or delayed nursing home admissions, morbidity, and mortality)
      • Nutrition intervention/plan of care and documentation is revised, if indicated
      • Documentation of nutrition monitoring and evaluation is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and Timed
      a CT = computed tomography.
      b DEXA = dual-energy x-ray absorptiometry.
      c Advocate: An advocate is a person who provides support and/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.
      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02 21 20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      )
      d 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, speech language pathologists, and occupational and physical therapists), depending on the needs of the patient/client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      e Academy EAL = Academy of Nutrition and Dietetics Evidence Analysis Library (www.andeal.org).
      f ASPEN = American Society for Parenteral and Enteral Nutrition (www.nutritioncare.org).
      g NHANES = National Health and Nutrition Examination Survey (www.cdc.gov/nchs/nhanes/about_nhanes.htm).
      h KDOQI = Kidney Disease Outcomes Quality Initiative (www.andeal.org/topic.cfm?menu=5303&cat=5557).
      i Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.
      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02 21 20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      ,
      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02 21 20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law and organization policies.
      Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872) – 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). US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      ,
      State Operations Manual. Appendix PP Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      Figure 2Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Nutrition Support. Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean client/patient/customer, family, participant, consumer, or any individual, group, or organization to which the RDN provides service.
      Standards of Professional Performance for Registered Dietitian Nutritionists in Nutrition Support

      Standard 1: Quality in Practice

      The registered dietitian nutritionist (RDN) 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 and supervised practice, 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
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Complies with applicable laws and regulations as related to their area(s) of practiceXXX
      1.1AComplies with state licensure or certification laws and federal or state regulations, if applicable, including telehealth and continuing education requirementsXXX
      1.2Performs within individual and statutory scope of practice and applicable laws and regulationsXXX
      1.2AUnderstands and works within individual scope of practice in nutrition support; assures:
      • job description/contract specifications comply with defined scope of practice, employer requirements, identified role, and professional responsibility
      • consistency with credentialing requirements (eg, Certified Nutrition Support Clinician [CNSC], Advanced Practitioner Certification in Clinical Nutrition [RDN-AP], Board Certified Specialist in Renal Nutrition [CSR] and/or Pediatric Critical Care Nutrition [CSPCC])
      XXX
      1.3Adheres to sound business and ethical billing practices applicable to the role and settingXXX
      1.3ADevelops understanding of the payment and reimbursement environments for hospitals, long-term care facilities, and home delivery of enteral nutrition (EN) or parenteral nutrition (PN) support (eg, Medicare, Medicaid, private payors)XXX
      1.3BOperates within ethical reporting of nutrition support services providedXXX
      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, ASPEN,
      ASPEN = American Society for Parenteral and Enteral Nutrition.
      Academy
      Academy = Academy of Nutrition and Dietetics.
      ) to improve the quality of services provided and to enhance customer-centered services (eg, nutrition support practice)
      XXX
      1.4AReviews existing national quality and safety recommendations and applies to nutrition support practiceXXX
      1.4BTranslates safety recommendations to enhance and improve nutrition support practice and meet patient/client needs (eg, during injectable-drug shortages, enteral misconnections)XX
      1.4CLeads local/state/national and/or international quality initiative efforts to support nutrition support goals and best practicesX
      1.4DMonitors changes to local, state, and national quality initiatives and leads quality improvement activities for nutrition support and related servicesX
      1.5Uses a systematic performance improvement (PI) model that is based on practice knowledge, evidence, research, and science for delivery of the highest quality servicesXXX
      1.5AIdentifies and participates in the use of an appropriate PI/quality improvement model (eg, PDCA
      PDCA = Plan-Do-Check-Act: A tool for continuous improvement.
      Cycle, Six Sigma,
      Six Sigma = a set of techniques and tools for process improvement developed by Motorola in 1986.
      Rapid Cycle Improvement,
      Rapid Cycle Improvement = defined by the Robert Wood Johnson Foundation as a “quality improvement method that identifies, implements and measures changes made to improve a process or a system.”14 This method is an important part of electronic health record (EHR) implementation because it allows continual improvement in the use of EHR technology.
      LEAN Thinking
      LEAN thinking = LEAN is centered on preserving value with less work. LEAN thinking changes the focus of management to one of eliminating waste and decreasing human effort. It is a production practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination.
      ) for assessing quality of nutrition support delivery
      XXX
      1.5A1Aligns selection of performance improvement method with the model preferred by the organization where the nutrition care is being deliveredXXX
      1.5A2Obtains training and mentors colleagues, students, and members of the 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, physician assistants, pharmacists, psychologists, social workers, speech language pathologists, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team on PI model(s) and leads PI initiatives
      XX
      1.5A3Develops and leads interprofessional quality improvement activities across the organization or systemX
      1.6Participates in or designs an outcomes-based management system to evaluate safety, effectiveness, quality, person-centeredness, equity, timeliness, and efficiency of practiceXXX
      1.6AInvolves colleagues and others, as applicable, in systematic outcomes managementXXX
      1.6A1Collaborates with interprofessional team in promoting and measuring quality of nutrition support delivery using systematic outcomes managementXXX
      1.6A2Prioritizes performance improvement projects based on organization priorities (eg, maximize reimbursement, regulation and accreditation requirements, achieving core measures)XX
      1.6BDefines expected outcomesXXX
      1.6B1Selects outcomes that are relevant to nutrition support delivery and are applicable to other interprofessional team leaders/stakeholders; seeks assistance if neededXXX
      1.6B2Identifies quality outcomes and defines targets for the nutrition support population/program or organization through evaluation, benchmarking, and monitoring environmental trendsXX
      1.6B3Interprets clinical, patient/client, functional, and financial outcomes associated with safe, effective, and efficient delivery of nutrition support therapy (ie, EN and PN support)XX
      1.6B4Determines desired nutrition-specific outcomes for the patient/client population through direct evaluation, benchmarking (eg, national standards, recognized practice guidelines), and evaluation of environmental trendsX
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6C1Identifies and uses nationally standardized and consensus-based nutrition support performance measuresXXX
      1.6C2Creates, implements, evaluates, and revises indicators to ensure they are S.M.A.R.T.XXX
      1.6DMeasures quality of services in terms of structure, process, and outcomesXXX
      1.6D1Uses and/or develops systematic quality improvement approach to collect data from multiple sources to measure quality of services against desired outcomesXXX
      1.6D2Uses systematic quality improvement approaches to collect and trend data regarding the population served (eg, demographics, acuity, clinical risk factors, morbidity, and mortality), services provided, and outcomesXXX
      1.6D3Uses a continuous quality and process improvement approach to measure use of nutrition support therapy against its outcomesXX
      1.6D4Uses aggregated data to evaluate current performance measurement process against expected outcomes to determine if changes are requiredXX
      1.6D5Assesses services using culturally competent engagement process in accordance with established performance criteria to improve practice and nutrition support careXX
      1.6D6Assesses effectiveness of nutrition support therapy in diverse populationsXX
      1.6D7Creates a data collection system to capture information for quality/outcome measurementX
      1.6D8Conducts data analysis, develops report of outcomes and improvement recommendations, and disseminates findingsX
      1.6EIncorporates electronic clinical quality measures to evaluate and improve care of patients/clients at risk for malnutrition or with malnutrition (www.eatrightpro.org/emeasures)XXX
      1.6E1Ensures that screening for nutrition risk is a component of admission process or incorporates into nutrition assessment using evidence-based screening tools for the setting and/or populationXXX
      1.6E2Collects data using clinical quality measures applicable to population and setting (eg, screening timeframes, severity of malnutrition, and services provided [eg, nutrition assessment, nutrition and/or dietary supplements, EN or PN, nutrition counseling, post-discharge services])XX
      1.6FDocuments outcomes and patient reported outcomes (eg, PROMIS
      PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
      )
      XXX
      1.6F1Documents outcomes related to patient/client population reported quality of life, depression, or other indicators and participates in evaluation and reportingXXX
      1.6F2Uses documented outcomes to reinforce current practice or implement changes in practiceXX
      1.6F3Synthesizes and shares effectiveness outcomes on programs and services with the nutrition and nutrition support communitiesX
      1.6GParticipates in, coordinates, or leads program participation in local, regional, or national registries and data warehouses used for tracking, benchmarking, and reporting service outcomesXXX
      1.6G1Actively promotes the inclusion of RDN-provided medical nutrition therapy (MNT) and nutrition support service components in local, regional, and/or national data registriesXX
      1.7Identifies and addresses potential and actual errors and hazards in provision of services or brings to attention of supervisors and team members as appropriateXXX
      1.7AEvaluates and ensures nutrition care is being delivered safely; seeks assistance if neededXXX
      1.7A1Refers patients/clients to appropriate services when error/hazard is outside practitioner’s scope of practiceXXX
      1.7A2Identifies and educates patients/clients/advocates/caregivers and other health care professionals regarding potential drug-food/nutrient interactionsXXX
      1.7A3Establishes processes and guidelines to prevent harm associated with nutrition support therapy (eg, enteral feeding tube misconnection, refeeding syndrome)XX
      1.7A4Maintains awareness of problematic product names, drug classes, and error-prevention recommendations provided by ISMP,
      ISMP = Institute for Safe Medication Practices (www.ismp.org/).
      FDA,
      FDA = US Food and Drug Administration (www.fda.gov/home).
      and USP
      USP = US Pharmacopeia (www.usp.org/).
      XX
      1.7A5Collaborates and leads an analysis of safety event reporting data and intervenes in sentinel events and near misses associated with EN and PN therapy (eg, medication or compounding errors, infection control, safe delivery)X
      1.8Compares actual performance to performance goals (eg, Gap Analysis, SWOT Analysis [Strengths, Weaknesses, Opportunities, and Threats], PDCA Cycle, DMAIC [Define, Measure, Analyze, Improve, Control])XXX
      1.8AReports and documents action plan to address identified gaps in care and/or service performanceXXX
      1.8BEvaluates individual and organization performance in comparison to goals and expected outcomesXX
      1.8CBenchmarks department/organization performance with national programs and standardsXX
      1.9Evaluates interventions and workflow process(es) and identifies service and delivery improvementsXXX
      1.9AUses evaluation data and/or collaborates with interprofessional team to identify program/service improvementsXXX
      1.9BConducts data analysis to evaluate the success of action plans in meeting patient/client and program goals; develops report of outcomes, and provides recommendationsXX
      1.9CGuides the development, testing, and redesign of organization/program evaluation systemsX
      1.10Improves or enhances patient/client/population care and/or services working with others based on measured outcomes and established goalsXXX
      1.10AAdjusts services and programs based on data and review of current evidence-based information in collaboration with interprofessional teamXXX
      1.10BLeads or collaborates in creating and improving systems, processes, and programs that support organization nutrition support-related core values and evidence-based guidelines for safe, quality careXX
      1.10CTranslates continuous quality improvement data to interprofessional team and manages changes in processesX
      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 systems specific to program(s)/service(s) are established and updated as needed and are evaluated for effectiveness in providing desired outcomes data and striving for excellence in collaboration with other team members
      • Performance indicators are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)
      • Aggregate outcomes results meet pre-established criteria
      • Quality improvement results direct refinement and advancement of practice
      Standard 2: Competence and Accountability

      The registered dietitian nutritionist (RDN) 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
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Adheres to the code(s) of ethics (eg, Academy/Commission on Dietetic Registration [CDR], other national organizations, and/or employer code of ethics)XXX
      2.1AExplains ethical responsibilities to patients/clients, peers, and other professionalsXXX
      2.1A1Analyzes ethics issues and addresses within the code of ethics; seeks guidance through consultation with appropriate professionalsXXX
      2.1A2Develops an ethical philosophy with the interprofessional teamXX
      2.1A3Serves as a resource for other health care practitioners on ethical issues related to nutrition support therapyX
      2.1BEducates patients/clients/consumers/customers and other caregivers on ethical issues related to nutrition support therapy for when making informed choices for type of nutrition care; seeks assistance if neededXXX
      2.2Integrates the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) into practice, self-evaluation, and professional developmentXXX
      2.2AIntegrates applicable focus area(s) SOP and/or SOPP into practice (www.eatrightpro.org/sop) (eg, Nephrology Nutrition, Pediatric Nutrition, Diabetes Care, Post-Acute Long-Term Care)XXX
      2.2BUses the SOP and SOPP for RDNs in Nutrition Support to assess performance at the appropriate level of practice; develops and implements a professional development plan to improve quality of practice and performance to advance practiceXXX
      2.2CReviews and recommends updates to organization policies, guidelines, and/or materials (eg, job descriptions, performance competencies, career ladders, acceptable performance level) reflecting the SOP and SOPP for RDNs in Nutrition Support; seeks assistance and approvals, if neededXX
      2.2DUses advanced practice experience and knowledge to define specific activities for levels of practice reflecting the SOP and SOPP for RDNs in Nutrition SupportX
      2.3Demonstrates and documents competence in practice and delivery of customer-centered service(s)XXX
      2.3AParticipates in the health care institution’s nutrition support-related activities to gain knowledge and skillsXXX
      2.3BDemonstrates nutrition support therapy knowledge, skills, and competence in areas such as: MNT, nutrition pharmacology, nutrition pathophysiology, research basis of practice, counseling, comorbiditiesXX
      2.3CExemplifies advanced skills, knowledge, and competence related to nutrition support therapy (eg, MNT, nutrition pharmacology, nutrition pathophysiology)X
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AIdentifies, acknowledges, and corrects errorsXXX
      2.4BExhibits professionalism and strives for improvement in practice (eg, manages change effectively, demonstrates assertiveness, listening and conflict resolution skills; and ability to build coalitions); seeks assistance if neededXXX
      2.4CDevelops and implements nutrition support-related policies and procedures that ensure staff accountability and responsibility; collaborates with interprofessional team and/or seeks guidance if neededXX
      2.5Conducts self-evaluation at regular intervalsXXX
      2.5AIdentifies needs for professional developmentXXX
      2.5BPrioritizes primary focus areas for professional developmentXXX
      2.5CActively pursues nutrition support continuing education opportunities locally, regionally, and nationallyXXX
      2.5DOutlines a plan to meet identified needs (eg, continuing education activities, engaging in mentor/mentee program, additional nutrition support-related coursework)XXX
      2.5D1Analyzes most effective methods to meet identified needsXX
      2.5EOutlines and prioritizes professional goals to assure that the developed plan is implemented most effectivelyXXX
      2.6Designs and implements plans for professional developmentXXX
      2.6ADevelops plan and documents professional development activities in career portfolio (eg, organizational policies and procedures, credentialing agency[ies])XXX
      2.6A1Pursues new opportunities for growth in professional practice by obtaining the knowledge, skills, experience, and mentoring needed to qualify for privileging or medical director approval for new service(s), or a specialty certificationXXX
      2.6A2Designs and implements a continuing education plan for advancing nutrition support knowledge and skillsXX
      2.6A3Includes a plan for achieving the knowledge, skills, and experience needed to qualify for or maintain certification(s) (eg, CNSC, CSPCC, CSR, RDN-AP) to support role(s) and responsibilitiesXX
      2.6A4Seeks resources and mentors outside of the field of nutrition support to gain skills that will translate into nutrition support practice (eg statistics class to improve ability to analyze and report results of research)X
      2.6BSelects and works with a mentor to guide nutrition support professional advancementXXX
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7ARecognizes strengths and limitations of current information/research/evidence when making recommendations; seeks assistance if neededXXX
      2.7BEvaluates practice for consistency with current evidence-based research and practice guidelines in nutrition support and other areas applicable to patient/client population and practice settingXXX
      2.7CInvestigates evidence-based research findings and incorporates into current practiceXX
      2.7DUses advanced training, research, and emerging theories to manage complex cases (eg, multiple comorbidities, complications) in the nutrition support populationX
      2.8Participates in peer review of others as applicable to role and responsibilitiesXXX
      2.8AEngages in peer review activities consistent with setting, responsibilities, and patient/client population (eg, peer evaluation, peer supervision, clinical chart review, and performance evaluations)XX
      2.8BDemonstrates knowledge and skills to train, mentor, and guide credentialed nutrition and dietetics practitioners and other support staffXX
      2.8CCreates and improves nutrition support evaluation tools and processes of peer-/self-review processX
      2.9Mentors and/or precepts othersXXX
      2.9AParticipates in mentoring entry-level and competent-level RDNs in nutrition support; and serves as preceptor for nutrition and dietetics students/interns; seeks to be inclusive of diverse individualsXXX
      2.9BContributes to the educational and professional development of credentialed nutrition and dietetics practitioners, students/interns, and health care professionals through formal and informal training activitiesXXX
      2.9CParticipates in mentor programs with credentialed nutrition and dietetics practitioners and other health care professionalsXX
      2.9DProvides case consultation and supervises other credentialed nutrition and dietetics practitioners (eg, RDNs new to nutrition support) in complex patient/client managementXX
      2.9EMentors individuals in advancing a specific skill set, such as feeding tube placement or indirect calorimetry interpretationX
      2.9FDesigns, operates, and evaluates mentor programs with credentialed nutrition and dietetics practitioners and other health care professionals (eg, resident training, fellow training, RDN obtaining a doctorate degree)X
      2.10Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations, and requirements of practice settingXXX
      2.10AParticipates in virtual and/or in-person continuing education opportunities relevant to nutrition support practice locally, regionally, and nationallyXXX
      2.10BInvestigates benefits of participation in nutrition support practice organizations and others to support career goalsXXX
      2.10CDevelops and implements a plan for achieving/advancing knowledge and practice (eg, specialty certification, research participation, speaking engagements)XXX
      2.10DObtains and maintains specialist credentials(s) (eg, CNSC, CSPCC, CSR, RDN-AP)XX
      2.10EDevelops programs, tools, and resources in support of assisting RDNs to obtain advanced practice certification in nutrition supportX
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects:
        • Code(s) 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
        • CDR 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
      • CDR recertification requirements are met
      Standard 3: Provision of Services

      The registered dietitian nutritionist (RDN) provides safe, quality service based on customer expectations, and needs, and the mission, vision, principles, and values of the organization/business.

      Rationale:

      Quality programs and services are designed, executed, and promoted based on the RDN’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
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      3.1Contributes to or leads in development and maintenance of programs/services that address needs of the customer or target population(s)XXX
      3.1AAligns program/service development with the mission, vision, principles, values, and service expectations and outputs of the organization/businessXXX
      3.1A1Develops and manages nutrition support programs tailored to the needs of the organization and the patient/client populationXX
      3.1A2Demonstrates need for specific nutrition support–related services (eg, home EN feeding clinic)XX
      3.1A3Leads an interprofessional nutrition support team, using expert knowledge and critical thinking to develop and implement nutrition support team services and policiesX
      3.1A4Designs, promotes, and seeks executive and/or medical staff commitment to new services that will meet organization goals and support desired nutrition outcomesX
      3.1BUses the needs, expectations, and desired outcomes of the customers/populations (eg, patients/clients, families, community, decision makers, administrators, client organization[s]) in program/service developmentXXX
      3.1B1Accommodates anticipated patient/client needs and identified goals and objectives in nutrition support therapy program development and deliveryXX
      3.1B2Leads systems of nutrition care and services for the provision of nutrition support therapies, coordinating nutrition care and services with other departments, home care servicesX
      3.1B3Synthesizes the results and outcomes of the services and programs to create new and unique offerings to meet patients/clients and advocates/caregivers needsX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Advocates for staffing and resources that support patient/client population, census/caseload, acuity, programs and services, and goalsXX
      3.1DProposes programs and services that are customer-centered, culturally appropriate, and minimize disparitiesXXX
      3.1D1Adapts practices to minimize or eliminate identified health disparities associated with culture, race, gender, socioeconomic status, age, and other factorsXXX
      3.1D2Develops/maintains programs and services that are tailored to patient/client population characteristics, disease states, health status, and social determinants of healthXX
      3.2Promotes public access and referral to credentialed nutrition and dietetics practitioners for quality food and nutrition programs and servicesXXX
      3.2AContributes to or designs referral systems that promote access to qualified, credentialed nutrition and dietetics practitionersXXX
      3.2A1Participates in or develops processes to receive or make referrals to other providers that address the needs of the nutrition support population (eg, pharmacist, respiratory therapist, mental/behavioral health professional, physical therapist, speech-language pathologist, bariatric surgery center)XX
      3.2A2Designs referral systems that match qualified RDNs in nutrition support practice with the needs of the publicXX
      3.2A3Designs, directs, and coordinates referral process and systemsX
      3.2BRefers customers to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practiceXXX
      3.2B1Collaborates with health care practitioners to facilitate referrals when patient/client need(s) is outside the RDN’s scope of practiceXXX
      3.2B2Verifies potential referral provider’s care reflects evidence-based information/research and professional standards of practiceXXX
      3.2B3Establishes and maintains networks to support the overall care and needs of the patients/clients receiving nutrition support therapyXX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Tracks data to evaluate efficiency and effectiveness of the nutrition referral processesXXX
      3.2C2Manages and/or leads data review and revision of the nutrition referral process and collaborative tools within the interprofessional teamXX
      3.2C3Leads the interprofessional team and other health care providers to review data and update the nutrition referral process and tools when neededX
      3.3Contributes to or designs customer-centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, resources of the customer, and social determinants of healthXXX
      3.3A1Recognizes the influence that culture, health literacy, and socioeconomic status have on patients’/clients’ health/illness experiences and population’s use of and access to health care servicesXXX
      3.3A2Anticipates the needs, goals, and resources of patients/clients receiving nutrition support therapyXX
      3.3A3Participates in or conducts needs assessment considering social determinants of health in collaboration with interprofessional team and community stakeholders to identify patient/client population’s needs and services that are availableXX
      3.3BUses knowledge of the customer’s/target population’s health conditions, cultural beliefs, and business objectives/services to guide design and delivery of customer-centered servicesXXX
      3.3B1Adapts program/service practices to meet the needs of an ethnically and culturally diverse populationXXX
      3.3B2Participates in or plans, develops, and implements systems of nutrition care and services reflecting needs of the populationXX
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target populationXXX
      3.3C1Advises on and uses systems or tools for communicating disease prevention and behavioral change principles with specific populationsXX
      3.3C2Designs systems or tools to communicate disease prevention and behavioral change with specific populationsX
      3.3DCollaborates with the customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomesXXX
      3.3D1Collaborates with patients/clients/caregivers, health care providers, and other support resources to create person-centered action plans that reflect the patients’/clients’ needs, wishes, desired outcomes, and program/service goals; documents decisions in medical record or according to organization/program guidelinesXXX
      3.3EInvolves customers in decision makingXXX
      3.3E1Designs nutrition support therapy regimens according to patients’/clients’ needs and lifestyles with consideration of and input from advocate/caregivers, when appropriateXXX
      3.3E2Facilitates patients’/clients’/advocates’ participation in health care decision making and goal setting, including preferences for use of EN or PN, and as part of end-of-life care when applicableXX
      3.3E3Develops and/or facilitates interprofessional team collaboration on design of nutrition support treatment plans to address patients/clients with complex needsX
      3.4Executes programs/services in an organized, collaborative, cost effective, and customer-centered mannerXXX
      3.4ACollaborates and coordinates with peers, colleagues, stakeholders, and within interprofessional teamsXXX
      3.4A1Works with interprofessional team for education/skill development and to demonstrate role of RDN and nutrition in care of individuals receiving EN or PNXXX
      3.4A2Collaborates with the interprofessional team to define the role of team members in identifying and monitoring safety practices in the delivery of nutrition support therapyXX
      3.4A3Facilitates interprofessional discussions and care planning for patients/clients with complex nutrition needs to achieve nutrition outcomes (eg, traumatic brain injury, post-transplantation, post-bariatric surgery)XX
      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)XXX
      3.4B1Incorporates standards for nutrition and nutrition support therapy (adult and pediatric) based on evidence-based guidelines and recommendations in design of programs and services; seeks assistance if neededXXX
      3.4B2Coordinates process to review and revise nutrition support screening tools and procedures within the interprofessional nutrition support team or serviceXX
      3.4B3Guides the development, implementation, and evaluation of nutrition support care, programs, screening initiatives, and services for individualsX
      3.4CUses and develops or contributes to selection, design and maintenance of policies, procedures (eg, discharge planning/transitions of care, emergency planning), 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 regulationsXXX
      3.4C1Collaborates/participates in the development and revision of policies, procedures, and evidence-based practice tools for nutrition support-related services applicable to population served by setting(s)XXX
      3.4C2Plans and implements systems of care and services for nutrition support therapy predicated on evidence-based strategies to prevent and/or treat disease in collaboration with othersXX
      3.4C3Collaborates with the interprofessional team and orients staff on new or revised policies/procedures/protocols; monitors success/follow-through, and amends as neededXX
      3.4C4Leads interprofessional process of monitoring, evaluating, improving, and implementing nutrition support-related protocols, guidelines, and practice toolsX
      3.4DUses and participates in or develops processes for order writing and other nutrition-related privileges, in collaboration with the medical staff,
      Medical staff: A medical staff is composed of doctors of medicine or osteopathy and may in accordance with state law, including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to be eligible for appointment by the governing body.7
      or medical director (eg, post-acute care settings, dialysis center, public health, community, free-standing clinic settings), consistent with state practice acts, federal and state regulations, organization policies, and medical staff rules, regulations, and bylaws
      XXX
      3.4D1Uses and participates in or leads development of processes for privileges or other facility-specific processes related to (but not limited to) implementing physician/non-physician practitioner
      Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.7,8 The term privileging is not referenced in the CMS long-term care (LTC) Regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law and organization policies.10,11
      -driven delegated orders or protocols, initiating or modifying orders for therapeutic diets, medical foods/nutrition supplements, dietary supplements, EN and PN, laboratory tests, medications, and adjustments to fluid therapies or electrolyte replacements
      XXX
      3.4D1iAdheres to organization- and medical staff/medical director–approved protocols and/or privileges for ordering or recommending therapeutic diets and nutrition-related services (eg, oral nutrition and/or vitamin/mineral supplements; EN or PN; supplemental water); seeks assistance if neededXXX
      3.4D1iiContributes to organization/medical staff process for identifying RDN privileges or delegated orders to support nutrition support care and services (eg, ordering or revising diet, medical food/nutrition supplements, EN or PN, vitamin and mineral supplements, or other nutrition-related orders [eg, ordering and inserting nasoenteric feeding tubes])XX
      3.4D1iiiNegotiates for and gains nutrition privileges at a systems level for new advances in practiceX
      3.4D2Uses and participates in or leads development of processes for privileging for provision of nutrition-related services, including (but not limited to) initiating and performing bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, providing home enteral nutrition or infusion management services (eg, ordering formula and supplies), and indirect calorimetry measurementsXXX
      3.4D2iAssures that role and direct care activities with home infusion patients/clients are consistent with home health/infusion program policy and physician orders, and demonstrated and documented competenceXX
      3.4D2iiCollaborates in the development of RDN privileges and/or physician-driven protocols for:
      • inserting and managing nasoenteric feeding tubes
      • conducting and/or interpreting the results of indirect calorimetry measurements
      • assessing body composition using DEXA,
        DEXA = dual energy x-ray absorptiometry.
        CT
        CT = computed tomography.
        scans, and ultrasound
      X
      3.4EComplies with established billing regulations, organization policies, grant funder guidelines, if applicable to role and setting, and adheres to ethical and transparent financial management and billing practicesXXX
      3.4FCommunicates with the interprofessional team and referring party consistent with the HIPAA rules for use and disclosure of customer’s protected health information (PHI)XXX
      3.4F1Follows regulations and organization/program policies for accessing, transporting, and storing information containing PHI when working in multiple sites; seeks assistance if neededXXX
      3.4F2Develops processes and tools to monitor adherence to HIPAA rules and/or address breaches in the protection of PHI and use of electronic medical records (onsite or through remote access)XX
      3.5Uses professional, technical, and support personnel appropriately in the delivery of customer-centered care or services in accordance with laws, regulations, and organization policies and proceduresXXX
      3.5AAssigns activities, including direct care to patients/clients, consistent with the qualifications, experience, and competence of professional, technical, and support personnelXXX
      3.5A1Determines capabilities/expertise of professional, technical, and support staff working with patients/clients to appropriately delegate tasksXX
      3.5BSupervises professional, technical, and support personnelXXX
      3.5B1Trains professional, technical, and support personnel and evaluates and documents their competence/skills following organization/program guidelinesXX
      3.6Designs and implements food delivery systems to meet the needs of customersXXX
      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 (eg, health care patients/clients, employee groups, schools, child and adult day care centers)XXX
      3.6A1Collects data and provides feedback on current food, EN and/or PN delivery systems serving individuals receiving nutrition support therapy in health care and community settingsXXX
      3.6BParticipates in, consults/collaborates with, 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 guidelinesXXX
      3.6B1Develops evidence-based disease or condition-specific guidelines for oral diet and nutrition supplement management for patients/clients who receive nutrition support therapyXX
      3.6B2Designs or provides consultation on in-house or commercially prepared nutrition supplement options that reflect and encourage normalized eating for individuals requiring supplemental EN or PN supportXX
      3.6CParticipates in, consults/collaborates with, or leads interprofessional process for determining medical foods/nutrition supplements, dietary supplements, EN and PN formularies, and delivery systems for target population(s)XXX
      3.6C1Actively participates in the process for determining EN and/or PN formulas and delivery systemsXXX
      3.6C2Provides guidance regarding medical foods/nutrition supplements, EN or PN formulas in accordance with best practices (eg, ASPEN, Academy, American Academy of Pediatrics)XX
      3.6C3Collaborates in or leads:
      • interprofessional process for determining EN and PN formulary and associated supplies
      • decision-making processes in case of shortages (eg, including emergencies or catastrophic events) and substitutions needed in enteral and/or parenteral formulations and delivery systems based on patient/client population and safety issues
      X
      3.7Maintains records of services providedXXX
      3.7ADocuments according to organization policies, procedures, standards, and systems including electronic health recordsXXX
      3.7A1Uses and participates in the design/revision of electronic health records applicable to setting and strategies for manual documentation as a backupXXX
      3.7A2Develops documentation/data collection procedures specifically suitable for nutrition support therapyXX
      3.7A3Spearheads development of electronic or other tools for measuring and reporting outcomes of nutrition support therapyX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7B1Develops data collection tools or collaborates with the interprofessional team to capture nutrition support–specific data through electronic health recordsXX
      3.7B2Seeks opportunities to contribute expertise to national bioinformatics/medical informatics projects, as applicable/requestedX
      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 servicesXXX
      3.7C1Analyzes and uses data to communicate value of nutrition and nutrition support services in relation to patient/client population and organization outcomes/goalsXX
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Prepares and presents nutrition care and service outcomes data for organization and accreditation organization if applicable; seeks assistance if neededXX
      3.8Advocates for provision of quality food and nutrition services as part of public policyXXX
      3.8ACommunicates with policy-makers regarding the benefit/cost of quality food and nutrition servicesXXX
      3.8A1Considers organization policies related to participating in advocacy activitiesXXX
      3.8A2Advocates for nutrition support therapy at the policy level (eg, addressing drug shortages, reimbursement)XXX
      3.8A3Promotes provision of and access to nutrition support therapy in health care organizations and at home by participating in legislative and policy-making activities that influence health services and practicesXX
      3.8A4Interacts and serves as a resource with legislators, payers, and policy makers to influence nutrition support care and services (eg, providing testimony at legislative and regulatory hearings and meetings)XX
      3.8A5Leads advocacy efforts in nutrition support by:
      • authoring articles or delivering presentations
      • contributing to development/review/comments/recommendations on policy, statutes, administrative rules and regulations
      • participating on state regulatory boards to influence regulations that may impact future practice
      X
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Reviews evidence-based research to identify and advocate for special needs populations whose health status will benefit from nutrition support therapyXXX
      3.8B2Identifies needs and opportunities for nutrition support population advocacy and participates in efforts to address issue(s)XX
      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)XXX
      3.8C1Participates in regional or national activities related to nutrition support policy and services; seeks opportunities for collaborationXX
      Examples of Outcomes for Standard 3: Provision of Services
      • Program/service design and systems reflect organization/business mission, vision, principles, 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 nutrition support assistance and food and nutrition services
      • Formularies 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 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 registered dietitian nutritionist (RDN) applies, participates in, and/or generates research to enhance practice. Evidence-based practice incorporates the best available research/evidence and information in the delivery of nutrition and dietetics services.

      Rationale:

      Application, participation, and generation of research promote improved safety and quality of nutrition and dietetics practice and services.
      Indicators for Standard 4: Application of Research
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Reviews best available research/evidence and information for application to practiceXXX
      4.1AUnderstands basic research design and methodologyXXX
      4.1BUses experience and critical thinking to evaluate strength of original research and evidence-based guidelines relevant to nutrition support, including limitations and potential bias(es)XX
      4.1CApplies evidence-based tools/resources (eg, Academy EAL, practice guidelines) to stimulate awareness and integration of current evidence into organization care protocols to standardize clinical practiceXX
      4.1DLeads application of new evidence in the practice settingX
      4.2Uses best available research/evidence and information as the foundation for evidence-based practiceXXX
      4.2AApplies evidence-based practice guidelines to provide consistent, safe, effective quality care for patients/clients receiving nutrition support; consults with more experienced practitioner for guidance as neededXXX
      4.2BIncorporates evidence-based research into practice and is able to summarize and cite current literature that supports the optimal approach for provision of safe, effective nutrition support therapyXX
      4.2CCritically evaluates and applies available scientific literature in situations where evidence-based guidelines for nutrition support are not yet established (eg, multisystem disease processes)X
      4.3Integrates best available research/evidence and information with best practices, clinical and managerial expertise, and customer valuesXXX
      4.3AAssesses and addresses system barriers and facilitators to adoption of evidence-based policies and proceduresXX
      4.3BIncorporates knowledge of cultural diversity when integrating research in a specific patient/client populationXX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AParticipates in efforts to apply research to practice (eg, journal clubs, professional discussion groups, collection of client baseline/outcomes data, listserv participation)XXX
      4.4BParticipates in practice-based research networks (eg, Academy’s Nutrition Research Network or EAL workgroup) and the development and/or implementation of practice-based research, national research databases; and adheres to Institutional Review Board (IRB) protocols and confidentiality guidelinesXXX
      4.4CMentors others in identifying and applying best available research/ evidence and integrating best practicesXX
      4.4DDesigns research study protocol(s) to address a clinical research question; uses resources to help guide the process, if neededXX
      4.4EIdentifies and initiates research relevant to nutrition support practice; acts as principal or co-investigator as part of collaborative research or with health care teams examining nutrition and nutrition support therapyX
      4.4FServes as advisor, preceptor, and/or committee member for graduate- and doctoral-level researchX
      4.4GDevelops or collaborates on research grant proposals and professional conference request for proposals to support continuing education of scientific community about nutrition supportX
      4.5Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizationsXXX
      4.5AIdentifies research issues/questions and participates in studies related to nutrition support care and servicesXXX
      4.5BCollaborates with interprofessional and/or interorganizational teams to perform and disseminate research on nutrition supportXX
      4.5CLeads interprofessional and/or interorganizational collaborative research activities and integration of research data into publications and presentations related to nutrition supportX
      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 registered dietitian nutritionist (RDN) effectively applies knowledge and expertise in communications.

      Rationale:

      The RDN works with others to achieve common goals by effectively sharing and applying unique knowledge, skills, and expertise in food, nutrition, dietetics, and management services.
      Indicators for Standard 5: Communication and Application of Knowledge
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      5.1Communicates and applies current knowledge and information based on evidenceXXX
      5.1ADemonstrates critical thinking and problem-solving skills when communicating with othersXXX
      5.1A1Demonstrates the ability to convey comprehension of foundational nutrition support concepts to other health care practitioners, patients/clients, and the publicXX
      5.1A2Demonstrates the ability to convey complex concepts to other health care practitioners. patients/clients, and the publicX
      5.1BInterprets regulatory, accreditation, and reimbursement programs and standards for organizations and providers that are specific to nutrition support (eg, Centers for Medicare and Medicaid Services [CMS], The Joint Commission)XX
      5.1CEvaluates public health trends and epidemiological reports common in patient/client population receiving nutrition support therapy, and applies data in clinical practice, professional activities, and work settingsXX
      5.1DServes as an expert resource/opinion leader for colleagues, other health care practitioners, the community, and outside agencies related to nutrition support therapyX
      5.2Selects appropriate information and the most effective communication method or format that considers customer-centered care and the needs of the individual/group/populationXXX
      5.2AUses communication methods (ie, oral, print, one-on-one, group, visual, electronic, and social media) targeted to various audiencesXXX
      5.2A1Determines the most appropriate information and best educational method to present/disseminate information based on the level of understanding of the individual and/or target audience (eg, advocate, care providers, professional colleagues, administrators, or the community)XXX
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision makingXXX
      5.2B1Identifies and uses web-based/electronic nutrition support tools/resources (eg, EN calculation apps) and telehealth platforms within worksite as appropriateXXX
      5.2B2Develops innovative approaches to using current information technology to deliver up-to-date information to nutrition support practitioners, other health care professionals, and the publicXX
      5.2B3Leads the development of patient-/client-, and system-specific technology that effectively conveys nutrition and nutrition support–related issues to diverse audiencesX
      5.3Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3AApplies current and emerging scientific knowledge of nutrition support when considering population’s culture, health status, behavior barriers, communication skills, and interprofessional team involvement; seeks guidance as neededXXX
      5.3BDemonstrates ability to integrate and communicate new knowledge to identified audienceXX
      5.3CLeads the integration of current and emerging knowledge from clinical research findings and consultation, in the management and resolution of complex problems in nutrition supportX
      5.4Shares current, evidence-based knowledge, and information with various audiencesXXX
      5.4AGuides customers, families, students, and interns in the application of knowledge and skillsXXX
      5.4A1Builds and maintains collaboration among researchers, educators, and decision makers to facilitate effective knowledge transfer for health practitioners’ education programsXX
      5.4BAssists individuals and groups to identify and secure appropriate and available educational and other resources and servicesXXX
      5.4B1Connects patients/clients/family/caregivers and support networks with programs/services and resources within the patients’/clients’ ethnic/cultural community to positively influence health-related decision making and outcomesXXX
      5.4B2Contributes to development of patient/client education materials/classesXXX
      5.4B3Establishes systematic processes to identify, track, and update available nutrition support resources for patients/clients and their family/care providersXX
      5.4B4Tracks and monitors use of patient/client population resources and impact on outcomes within the specific ethnic/cultural community, and collaborates as appropriateX
      5.4CUses professional writing and verbal skills in all types of communicationsXXX
      5.4DReflects knowledge of population characteristics in communication methods (eg, literacy and numeracy levels, need for translation of written materials and/or a translator, communication skills, and learning, vision or hearing disabilities)XXX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management team, organization, and communityXXX
      5.5AContributes formally and informally to the interprofessional team (eg, shares relevant articles, investigates queries, serves as nutrition subject matter expert)XXX
      5.5BCommunicates with members of the interprofessional team and other providers to promote the use of evidence-based guidelines/practices and the EALXXX
      5.5CDevelops and/or presents programs emphasizing the safe and effective delivery of nutrition support therapyXX
      5.5DLeads interprofessional collaborations at an organization or system levelX
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6APresents nutrition support guidelines and research at the local level (eg, community groups, interprofessional team, colleagues)XXX
      5.6BCompiles and interprets performance improvement and research findings and reports results to interprofessional team and others within the organizationXX
      5.6CAuthors peer-reviewed nutrition support publications and authoritative articles for credentialed nutrition and dietetics practitioners, other health care practitioners, and consumersXX
      5.6DPresents evidence-based nutrition support research, guidelines, and information at professional meetings and conferences (eg, local, regional, national, or international)XX
      5.6ELeads collation of performance improvement and research data into publications (eg, systematic reviews, practice and position papers), and presentations to influence nutrition support practiceX
      5.6FServes in a leadership role for nutrition support- or nutrition-related publications (eg, editor or editorial board member of peer-reviewed journal[s]) and program planning at regional and national levelsX
      5.7Seeks 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) providing food and nutrition expertiseXXX
      5.7AServes as a nutrition support resource as an active member of local or state organizationsXXX
      5.7BServes as a nutrition support resource as an active member of coalitions, task forces or advisory boardsXX
      5.7CPursues leadership development opportunities as a subject matter expert and organizes work groups in local, regional, and national nutrition support–related organizations, coalitions, or advisory boardsXX
      5.7DIdentifies new opportunities for leadership and cross-discipline dialogue to promote nutrition and dietetics practice in a broader contextX
      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 registered dietitian nutritionist (RDN) uses resources effectively and efficiently.

      Rationale:

      The RDN demonstrates leadership through strategic management of time, finances, facilities, supplies, technology, natural and human resources.
      Indicators for Standard 6: Utilization and Management of Resources
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      6.1Uses a systematic approach to manage resources and improve outcomesXXX
      6.1AIdentifies efficient workflow patterns to optimize time management and maximize patient/client care outcomesXXX
      6.1A1Recognizes and uses resources (eg, education materials, training tools, staff time) effectively in the provision of nutrition support services to achieve desired outcomesXXX
      6.1A2Proposes changes to organization workflow patterns to improve efficiency and patient/client care outcomesXX
      6.1A3Collaborates on adjusting staffing and/or workflow patterns to optimize patient/client care outcomes through efficient use of resourcesX
      6.1BSelects clinically appropriate and cost-effective nutrition support therapy components (eg, EN formulas, PN components, equipment)XXX
      6.1B1Develops, with the interprofessional team, guidelines for clinically appropriate and cost-effective use of nutrition support therapyXX
      6.1B2Analyzes and reports nutrition support therapy use and related costs; modifies organization/department practices based on results in collaboration with the interprofessional teamX
      6.1B3Serves as manager or coordinator of an organization’s nutrition support team/service (eg, physician, pharmacist, RDN, nurse, and other disciplines according to the needs of the organization)X
      6.2Evaluates management of resources with the use of standardized performance measures and benchmarking as applicableXXX
      6.2AUses the Standards of Excellence Metric Tool to self-assess quality in leadership, organization, practice, and outcomes for an organization (www.eatrightpro.org/excellencetool)XXX
      6.2A1Participates in or develops programs that meet the Standards of Excellence in Nutrition and Dietetics for OrganizationsXX
      6.2BCollects or contributes data and participates in analyzing program resources/service participation and expense data to evaluate and adjust programs and servicesXXX
      6.2B1Leads and participates in data collection and analysis regarding the population served, services provided, and outcomes (eg, demographic characteristics, staff hours, consult requests, staffing benchmarking, and payment/revenue)XX
      6.2B2Analyzes productivity and/or nutrition support therapy product usage data and recommends or modifies department practice based on comparison to standardized benchmarksX
      6.2CLeads or facilitates periodic operational review, reflecting evaluation of performance and benchmarking data, to manage resources and modifications to processes for delivery of nutrition support therapy and servicesX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and productsXXX
      6.3AConsiders safe, effective, and cost-effective nutrition support therapy during nutrition assessment and treatment processXXX
      6.3A1Participates in evaluation, selection, and implementation of new products and services to ensure safe, optimal, and cost-effective delivery of nutrition support care and servicesXX
      6.3A2Monitors and compares impact of nutrition support therapy (positive, negative, no change) and cost-effectiveness of the therapy, including product selection, equipment, monitoring, and staffingX
      6.3A3Employs mechanisms to ensure clinical effectiveness and patient/client safety while planning and delivering nutrition support-related products and servicesX
      6.3BDemonstrates understanding of and adheres to regulations and accreditation standards relevant to nutrition support (eg, CMS Conditions for Coverage/Conditions of Participation, CMS MNT coverage guidelines when applicable, accreditation organization standards)XXX
      6.4Participates in quality assurance and performance improvement (QAPI) and documents outcomes and best practices relative to resource managementXXX
      6.4AParticipates actively in QAPI, including collecting, documenting, and analyzing data relevant to resource use (eg, fiscal, personnel, services, materials, supplies) and recommends modificationsXXX
      6.4BUses data to modify resource management and/or delivery of services (eg, staffing, triage, nutrition supplements, education materials/tools) as necessary to achieve desired outcomesXX
      6.4CReviews and reports findings according to organization’s process (eg, department leadership, facility committee); develops or revises procedures in collaboration with interprofessional team, if applicableXX
      6.4DIntegrates quality measures and performance improvement processes into management of human and financial resources and information technologyX
      6.4EShares QAPI results via professional presentations at regional and national levels and publishes in peer-reviewed journalsX
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators)XXX
      6.5AParticipates in developing and/or conducting regular surveys with patients/clients/advocates, interprofessional team members, community participants and stakeholders to assess satisfaction; seeks assistance if neededXXX
      6.5BDevelops or modifies programs and services based on data analysis to improve stakeholder (eg, patients/clients/advocates, caregivers, employees, administration) satisfaction with nutrition support servicesXX
      6.5CResolves internal and external problems that may affect the delivery of nutrition support servicesXX
      6.5DLeads interprofessional team to maximize stakeholder satisfaction with nutrition support servicesX
      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
      • Key performance indicators are identified in alignment with organization mission, vision, principles, and values
      a ASPEN = American Society for Parenteral and Enteral Nutrition.
      b Academy = Academy of Nutrition and Dietetics.
      c PDCA = Plan-Do-Check-Act: A tool for continuous improvement.
      d Six Sigma = a set of techniques and tools for process improvement developed by Motorola in 1986.
      e Rapid Cycle Improvement = defined by the Robert Wood Johnson Foundation as a “quality improvement method that identifies, implements and measures changes made to improve a process or a system.” This method is an important part of electronic health record (EHR) implementation because it allows continual improvement in the use of EHR technology.
      f LEAN thinking = LEAN is centered on preserving value with less work. LEAN thinking changes the focus of management to one of eliminating waste and decreasing human effort. It is a production practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination.
      g 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, physician assistants, pharmacists, psychologists, social workers, speech language pathologists, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      h PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
      i ISMP = Institute for Safe Medication Practices (www.ismp.org/).
      j FDA = US Food and Drug Administration (www.fda.gov/home).
      k USP = US Pharmacopeia (www.usp.org/).
      l Medical staff: A medical staff is composed of doctors of medicine or osteopathy and may in accordance with state law, including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to be eligible for appointment by the governing body.
      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02 21 20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      m Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.
      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02 21 20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      ,
      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02 21 20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      The term privileging is not referenced in the CMS long-term care (LTC) Regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law and organization policies.
      Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872) – 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). US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      ,
      State Operations Manual. Appendix PP Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      n DEXA = dual energy x-ray absorptiometry.
      o CT = computed tomography.

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      Biography

      M. L. Corrigan works in Medical Affairs, Baxter Healthcare, Deerfield IL 60015 (at the time the manuscript was written, she was a clinical nutrition manager, Cleveland Clinic, Cleveland, OH).
      E. Bobo is a dietitian clinic coordinator and a clinical dietitian, Nemours Children’s Specialty Care, Jacksonville, FL.
      C. Rollins is a manager, Quality Programs, Option Care Health, Rochester, IL.
      K. M. Mogensen is a team leader dietitian specialist, Brigham and Women’s Hospital, Boston, MA.