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From the Academy Standards of Practice and Professional Performance| Volume 122, ISSUE 11, P2134-2149.e50, November 01, 2022

Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Pediatric Nutrition

      Abstract

      Pediatrics spans the first 2 decades of life and is a dynamic period with rapid changes in size and physical ability, cognitive development, behavior, and nutrient needs. Registered dietitian nutritionists (RDNs) who work with the pediatric population provide the nutrition knowledge and support needed to promote optimal health and nutrition during this time across a variety of settings. The Pediatric Nutrition Practice Group, 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 with pediatric populations. The SOP and SOPP for RDNs in Pediatric Nutrition provide indicators that describe 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 illustrate how these standards apply to practice. The SOP and SOPP are intended to be used as a self-evaluation tool for assuring competent practice in pediatric nutrition and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.
      Approved May 2022 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Pediatric Nutrition Practice Group of the Academy. Scheduled review date: June 2028. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Pediatric Nutrition may be addressed to Academy Quality Management Staff: Dana Buelsing Sowards, MS, manager, Quality Standards Operations; and Carol J. Gilmore, MS, RDN, LD, FADA, FAND, scope/standards of practice specialist, Quality Management at [email protected].
      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.
      Editor’s note: Figures 1 and 2 that accompany this article are available online at www.jandonling.org.The Pediatric Nutrition Practice Group of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee, has revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Pediatric Nutrition originally published in 2009 and revised in 2015.
      • 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.
      This document, “Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Pediatric Nutrition,” reflects advances in pediatric nutrition practice during the past 7 years and replaces the 2015 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,
      2018 Code of Ethics for the Nutrition and Dietetics Profession. Academy of Nutrition and Dietetics/Commission on Dietetic Registration (CDR).
      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.
      Scope of practice in nutrition and dietetics is composed of statutory and individual components, includes codes of ethics (eg, Academy/CDR, other national 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, scope of practice is typically established within the practice act 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 https://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. 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, Board Certified Specialist in Pediatric Nutrition [CSP] and/or Pediatric Critical Care Nutrition [CSPCC]; Certified Nutrition Support Clinician [CNSC], Certified Case Manager [CCM], International Board Certified Lactation Consultant [IBCLC], School Nutrition Specialist [SNS], or Certified Professional in Healthcare Quality [CPHQ]). 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 RDNs with critically evaluating their personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.
      Scope of Practice decision algorithm. Academy of Nutrition and Dietetics.
      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 now 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 (https://www.eatrightpro.org/dietorders/). For assistance, refer questions to the Academy’s State Affiliate organization.
      Medical staff oversight of an RDN occurs in 1 of 2 ways. A hospital has the regulatory flexibility to appoint RDNs to the medical staff and grant the RDNs 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 will be based on 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. Supervision 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 (https://www.eatrightpro.org/practice/quality-management/national-quality-accreditation-and-regulations/centers-for-medicare-and-medicaid-services). Review state 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 print).
      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 https://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 the following 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 pediatric nutrition 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 pediatric nutrition and dietetics 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) for the SOP and SOPP for RDNs in Pediatric Nutrition were revised with input and consensus of content experts representing varied practice and geographic perspectives. The SOP and SOPP for RDNs in Pediatric Nutrition were reviewed and approved by the Executive Committee of the Pediatric Nutrition Practice Group 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 practice at the competent level and manages their professional development to achieve individual goals. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDNs in Pediatric Nutrition. In Academy focus areas, the 3 levels of practice are 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 pediatric nutrition screening, pediatric weight management, type 1 diabetes, cystic fibrosis, and preterm infant enteral nutrition. 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/caregiver/population in shared decision making.
      Figure 3Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Pediatric Nutrition.
      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 registered dietitian nutritionists (RDNs) are accountable. The SOP for RDNs in Pediatric Nutrition 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 Pediatric Nutrition are authoritative statements that describe behavior in the professional role, including activities categorized in the following 6 standards: Quality in Practice; Competence and Accountability; Provision of Services; Application of Research; Communication and Application of Knowledge; and Utilization and Management of Resources.
      SOP and SOPP are complementary standards and serve as evaluation resources. All indicators may not be applicable to all RDNs’ practices 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
      Scope of Practice decision algorithm. Academy of Nutrition and Dietetics.
      is designed specifically 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, with the recognition that parents, families, and caregivers play unique roles in the care of infants, children, and youth. Patient/client could also mean client/patient, resident, participant, consumer, or any individual or group who receives pediatric nutrition care and services. Customer is used in the SOPP as a universal term. Customer could also mean client/patient, client/patient/caregiver, participant, consumer, or any individual, group, or organization to which the RDN provides services. Pediatric nutrition care and services are provided to individuals from birth to 21 years of age. The SOP and SOPP are not limited to the clinical setting. In addition, it is recognized that the families and caregivers of patients/clients, 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, 1 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 pediatric nutrition (see image below). In addition, the core indicators have been expanded to reflect the unique expectations for the RDN in pediatric nutrition.
      Standards described as proficient level of practice in this document are not equivalent to Commission on Dietetic Registration certification, Board Certified as a Specialist in Pediatric Nutrition (CSP) and/or Board Certified Specialist in Pediatric Critical Care Nutrition (CSPCC). Rather, the CSP and CSPCC designations recognize the skill level of RDNs who have developed and demonstrated through successful completion of the certification examination, pediatric nutrition, and/or pediatric critical care nutrition knowledge and application beyond the competent practitioner and demonstrates, at a minimum, proficient-level skills. An RDN with a CSP and/or CSPCC designation has demonstrated additional knowledge, skills, and experience in pediatric and/or pediatric critical care nutrition by the attainment of a specialist credential(s).

      Competent Practitioner

      A competent practitioner in nutrition and dietetics 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 practice area that requires focused knowledge, skills, and experience.
      Definition of terms. Academy of Nutrition and Dietetics.
      A competent practitioner 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 have responsibilities across several areas of practice, including, but not limited to community, clinical, consultation and business, research, education, and food and nutrition management.
      RDNs with a competent level of knowledge in pediatric nutrition understand the influence of growth and development on nutrient needs, nutrition status, and health-related behaviors.
      Pediatric Nutrition Care Manual. Academy of Nutrition and Dietetics.
      They apply this knowledge to their specific practice area, for example, clinical dietetics, community nutrition, or consultation. In addition to didactic education activities (eg, workshops and courses), training and expertise can be obtained through formal mentorships and informal networking.

      Proficient Practitioner

      A proficient practitioner is an RDN who is generally 3 or more years beyond credentialing and entry into the profession and consistently provides safe and reliable service, has obtained operational job performance skills, and is successful in their chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, judgment, and experience in pediatric nutrition and dietetics practice. A proficient RDN may have obtained or be working toward the education, knowledge, and experience to be eligible for Board Certification as a Specialist in Pediatric Nutrition (CSP), and/or Board Certification as a Specialist in Pediatric Critical Care Nutrition (CSPCC) to demonstrate proficiency.
      Definition of terms. Academy of Nutrition and Dietetics.
      RDNs who practice at the proficient level in pediatric nutrition may develop expertise in a subspecialty (eg, neonatal nutrition, intellectual or developmental disabilities, or nutrition support). They often are important members of interprofessional teams and serve as nutrition resources within their organizations.

      Expert Practitioner

      An expert practitioner is an RDN who is 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; expanding knowledge, skills, and experience; and feedback from others. An expert has the ability to quickly identify what is happening and how to approach the situation. Expert RDNs use skills learned in nutrition and dietetics, such as leadership and quality practice, and apply them to other areas for further success and opportunities.
      Definition of terms. Academy of Nutrition and Dietetics.
      An expert RDN may be a specialist RDN or may have expanded roles within their setting and may possess advanced credentials, such as the CDR Advanced Practitioner Certification in Clinical Nutrition (RDN-AP), CSP, and/or CSPCC, or advanced degrees, such as a doctorate in clinical nutrition (DCN). Generally, expert-level practice is more complex and the practitioner has a high degree of professional autonomy and responsibility.
      RDNs who practice at the expert level in pediatric nutrition are often leaders in their fields and organizations. They use their solid foundation in pediatric nutrition, extensive experience, and holistic understanding to influence practice at an organization or health system level.
      These Standards, along with the Academy/CDR Code of Ethics,
      2018 Code of Ethics for the Nutrition and Dietetics Profession. Academy of Nutrition and Dietetics/Commission on Dietetic Registration (CDR).
      answer the questions: Why is an RDN uniquely qualified to provide pediatric nutrition and dietetics services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, efficient, equitable, and quality pediatric nutrition care and service at the competent, proficient, and expert levels?

      Overview

      Pediatric nutrition encompasses a broad practice area. RDNs provide care for neonates, infants, children, and adolescents from birth to 21 years of age across a variety of settings, including but not limited to community hospitals and tertiary care centers, outpatient clinics, public health programs, schools, and childcare settings.

      Pediatrics Requires a Unique Skillset

      Pediatrics spans the first 2 decades of life. It is a dynamic period with rapid changes in size and physical ability, cognitive development, behavior, and nutrient needs
      Promoting Healthy Nutrition.
      (see Figure 4). RDNs working with pediatric populations need:
      • comprehensive knowledge of all the relationships between developmental stages, intake, and nutrition;
      • an understanding of how developmental changes and other factors, such as medical conditions, socioeconomic factors, and environment, affect overall nutrition status; and
      • knowledge and grasp of cognitive and physical development, along with behavior change and family, socioeconomic, and cultural dynamics when designing nutrition interventions for individuals, care guidelines, educational strategies for groups, and public policy.
      Figure 4Pediatric developmental stages: nutrition-related considerations.
      Promoting Healthy Nutrition.
      Note: The descriptions are generalizations and may not apply to an individual infant, child, or adolescent for a variety of reasons. Evaluations and plans of care consider the specific characteristics and needs of each individual.
      Developmental Stages
      Infancy (0-11 months)Early Childhood (1-4 years)Middle Childhood (5-10 years)Adolescence (11-21 years)
      Growth and Physical Development
      • Period of most rapid growth and physical development
      • High nutrient needs to meet growth demands
      • Initial reflexes fade; feeding becomes a more coordinated, volitional activity
      • As infants grow, able to consume larger volumes; maturation of digestive system allows absorption of more complex foods
      • Physical growth rate slows
      • Appetite and amount of food consumed may decrease or be unpredictable
      • Self-feeding skills develop and progress toward ability to use utensils
      • Motor skills become more refined; can begin to help with food preparation
      • Overall, slow, steady rate of physical growth
      • Appetite and intake can accompany growth spurts and decrease during periods of slower growth
      • Body composition and shape remain relatively constant; adiposity increases during pre-adolescence (9-11 years for girls, 10-12 years for boys)
      • Rapid growth and development (second only to infancy)
      • Dramatic increase in nutrient needs
      • Wide variation in energy and other macronutrient needs; depends on timing of pubertal growth spurt, physiologic maturation, physical activity
      Social and Emotional Development
      • Learning to trust that needs will be met by caregivers
      • A nurturing environment and positive feeding patterns will promote healthy eating habits
      • Curiosity and independence emerge
      • Toddlers often leery of new foods
      • 3- to 4-year-olds may be less impulsive and able to follow instructions
      • A structured but pleasant mealtime environment sets the stage for positive caregiver–child interactions
      • Begin to develop, refine sense of self
      • Memory, logic, and related skills increase
      • May become overly concerned about appearance
      • Mealtimes take on more social significance, and outside sources begin to influence decisions and attitudes
      • Further establish and express identity
      • Become independent young adult
      • Growing capacity for abstract thought, problem-solving, future-oriented thinking
      • May use food to establish individuality and express identity
      General Nutrition-Related Messaging
      • Identify, assess, and respond to infant’s cues
      • Foster development of healthy eating behaviors
      • Introduce nutrition education concepts, with focus on enjoyment of food
      • Provide guidance, examples for selecting food, especially outside the home
      Nutrition-Related Concerns/Issues
      • Prevention of iron and vitamin D deficiency
      • Introducing complementary foods
      • Human milk and/or formula decision; address barriers
      • Choking prevention
      • Transition from on-demand to structured meals and snacks by end of this phase
      • Addressing eating behavior, food jags, picky eating
      • More independence with food choices and meals outside the home
      • More meals outside the home, tendency to skip meals, dieting
      • Screening for and addressing body image issues, disordered eating

      Settings

      Clinical services are offered in acute care (including community hospitals and tertiary care centers), primary, outpatient specialty, and long-term care settings. Pediatric public health and community nutrition services are far-reaching; in 2020, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program) served almost one-half of the infants born in the United States, with 6.2 million participants per month.
      WIC Program
      Economic Research Service, US Department of Agriculture.
      Approximately 44% of Supplemental Nutrition Assistance Program participants are children.
      Food Security and Nutrition Assistance
      Economic Research Service, US Department of Agriculture.
      Pediatric RDNs also work in school nutrition and childcare programs, home health care, sports nutrition, global nutrition, business and industry, academia, and research.

      Importance of Pediatric Nutrition

      Healthy People 2030, Bright Futures, and Dietary Guidelines for Americans, 2020-2025 are professional and federal pediatric program initiatives that emphasize the importance of pediatric nutrition, and many of the public health goals called for by these initiatives are planned for and carried out by RDNs.
      Promoting Healthy Nutrition.
      ,
      Healthy People 2030: Nutrition and healthy eating
      Office of Disease Prevention and Health Promotion, US Department of Health and Human Services.
      ,
      The Bright Futures initiative led by the American Academy of Pediatrics has identified the following as essential components of nutrition, and these components are the foundation for general pediatric nutrition across practice settings:
      • nutrition for appropriate growth;
      • nutrition and development of feeding and eating skills;
      • healthy feeding and eating habits;
      • healthy eating relationships; and
      • nutrition for children and youth with special health care needs.
        Promoting Healthy Nutrition.
      RDNs in pediatric practice provide the nutrition knowledge and support needed to promote optimal health and nutrition from birth through adolescence. This may include human milk feeding promotion and support and providing guidance around infant feeding practices, such as timing of feeds, feeding method, supplementation (eg, vitamin/mineral and human milk supplemented with formula), and formula preparation.
      Promoting Healthy Nutrition.
      ,
      Pediatric Nutrition Practice Group
      As infancy turns into early childhood, RDNs help families establish healthy eating habits and food choices, as well as address nutrition and related problems, such as iron deficiency, constipation, and other conditions.
      Promoting Healthy Nutrition.
      RDNs also work with youth and adolescents as they become more independent; sports nutrition and body image are frequent topics commonly addressed around this age.
      Pediatric RDNs play critical roles in identifying and addressing barriers to optimum nutrition status, recognizing the influence of the feeding environment, culture, and socioeconomic factors. They work to reduce food insecurity and the potential for associated undernutrition at individual, community, and population levels.
      Practice tips: Addressing food and nutrition insecurity. Academy of Nutrition and Dietetics.

      Subspecialties Within Pediatric Nutrition

      Subspecialties exist in pediatric nutrition and each requires specialized knowledge and skillsets, in addition to a solid foundation in pediatrics. Overweight and obesity affect nearly 18.5% of children in the United States, and pediatric RDNs are essential to assessment and intervention, as well as prevention efforts.
      Overweight & obesity: Childhood obesity facts. US Department of Health and Human Services, Centers for Disease Control and Prevention.
      • Barlow S.E.
      Expert Committee
      Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report.
      • Kirk S.
      • Ogata B.
      • Wichert E.
      Treatment of pediatric overweight and obesity: Position of the Academy of Nutrition and Dietetics based on an umbrella review of systematic reviews.
      • Hoelscher D.M.
      • Brann L.S.
      • O’Brien S.
      Prevention of pediatric overweight and obesity: Position of the Academy of Nutrition and Dietetics based on an umbrella review of systematic reviews.
      The prevalence of malnutrition (undernutrition) in pediatric patients seeking care or hospitalized varies considerably, ranging from 2.5% to 51%,
      • McCarthy A.
      • Delvin E.
      • Marcil V.
      • et al.
      Prevalence of malnutrition in pediatric hospitals in developed and in-transition countries: The impact of hospital practices.
      and pediatric RDNs are the experts in identifying, assessing, and treating malnutrition, often combining several areas of subspecialty expertise, for example, pediatric nutrition, nutrition support,
      • 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 critical care nutrition.
      • Becker P.
      • Carney L.N.
      • Corkins M.R.
      • et al.
      Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition).
      Pediatric RDNs are also crucial members of interprofessional teams to treat diabetes and related disorders
      American Diabetes Association Professional Practice Committee
      14. Children and adolescents: Standards of medical care in diabetes – 2022.
      ; eating disorders and disordered eating
      • Hackert A.N.
      • Kniskern M.A.
      • Beasley T.M.
      Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders.
      ; pulmonary conditions; autism and other neurodevelopmental disorders; genetic metabolic disorders; and many other chronic conditions.
      • Conway C.
      • Lemons S.
      • Terrazas L.
      Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities.
      RDNs working in neonatal intensive care units require training and experience in acute care, nutrition support, and the unique needs of infants born prematurely.
      In many instances, subspecialties intersect, and several focus area SOP and SOPP apply. For example, the Pediatric Nutrition and the Intellectual and Developmental Disabilities focus area standards apply to RDNs who work with children with autism and other intellectual disabilities.
      • Conway C.
      • Lemons S.
      • Terrazas L.
      Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities.
      Other applicable focus area standards include diabetes care,
      • 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.
      nutrition support,
      • Corrigan M.L.
      • Bobo E.
      • Rollings C.
      • Mogensen K.M.
      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.
      oncology nutrition,
      • Charuhas P.
      • Schilling K.
      • Palko R.
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Oncology Nutrition.
      nephrology nutrition,
      • 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.
      eating disorders,
      • Hackert A.N.
      • Kniskern M.A.
      • Beasley T.M.
      Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders.
      and sports and human performance nutrition.
      • Daigle K.
      • Subach R.
      • Valliant M.
      Academy of Nutrition and Dietetics: Revised 2021 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sports and Human Performance Nutrition.
      Subspecialties require RDNs’ familiarity with resources and clinical guidelines, collaboration with interprofessional team members, and ongoing continuing education. See Figure 5 for selected relevant resources. Referral to an RDN experienced with the subspecialty is necessary when the patient’s/client’s needs are beyond the general practice RDN’s individual scope of practice or experience level.
      Figure 5Resources for registered dietitian nutritionists in pediatric nutrition (not all inclusive).
      ResourceAddressDescription
      Academy of Nutrition and Dietetics (Academy)
      Academy Pediatric Nutrition Practice Group (PNPG)https://www.pnpg.org/The PNPG provides various resources in pediatric nutrition, such as an online forum, webinars, practice group library, and a newsletter. PNPG’s newsletter provides PNPG members with resources containing articles, case studies, continuing professional education articles, and a platform to share news within the practice group.
      Academy Pocket Guide to Children with Special Health Care and Nutritional Needs, 2nd ed. (eBook)https://www.eatrightstore.org/product-type/ebooks/academy-of-nutrition-and-dietetics-pocket-guide-to-children-with-special-health-care-and-nutritionalThis pocket guide provides registered dietitian nutritionists (RDNs) critical information on working with children with special health care needs, including Down syndrome, autism, cerebral palsy, cystic fibrosis, Prader-Willi syndrome, seizure disorders, among others. It includes guidelines for assessing growth; recommendations for nutrition screening, assessment, and intervention; practical advice; and case studies.
      Evidence Analysis Library (EAL)https://www.andeal.org/The EAL is a series of systematic reviews based on predefined criteria that use an objective and transparent methodology to assess food and nutrition-related science. EAL topics include nutrition guidance for healthy children, nutrition screening for pediatrics, pediatric weight management; and preterm infant very-low-birthweight enteral nutrition.
      Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities, 3rd ed. (eBook)https://www.eatrightstore.org/product-type/ebooks/infant-and-pediatric-feedings-ebookThis book is an authoritative reference guide on infant and pediatric feeding. It addresses current information on human milk and formula storage, handling, and preparation techniques. There is additional information on centralized infant and pediatric formula preparation, use of blenderized (real food) tube feedings in hospital settings; donor human milk, along with guidelines on human milk products; and contains information related to lacto-engineering techniques and current research.
      Journal of the Academy of Nutrition and Dieteticshttps://jandonline.org/The Academy’s Journal offers various collections relevant to pediatric nutrition: Pediatric Malnutrition; Childhood Overweight and Obesity; Pregnancy; and School Nutrition.
      Kids EatRighthttps://www.eatrightfoundation.org/why-it-matters/public-education/kids-eat-right/Kids Eat Right is a campaign launched by the Academy Foundation to support public education projects and programs that address the national health concern of obesity among children. It includes links to websites, such as the Kids Eat Right section of eatright.org, resources, webinars, and toolkits.
      Pediatric Nutrition, 8th ed.https://www.eatrightstore.org/product-type/books/pediatric-nutrition-8th-editionThis book contains more than 50 chapters with the latest information on nutrient metabolism to support normal development of infants and children, as well as those born with congenital abnormalities or disorders of metabolism and those with acute and chronic illnesses.
      Pediatric Nutrition Care Manualhttps://www.nutritioncaremanual.org/pediatric-nutrition-careThe Pediatric Nutrition Care Manual gives access to the largest client education library of evidence-based pediatric education materials and resources. It contains clinical recommendations on more than 90 topics, access to PNPG’s Infant Formula and Feeding Recipe Tables, and the client education library containing more than 150 handouts.
      Pediatric Weight Management: Evidence-Based Nutrition Practice Guidelines Quick Reference Toolhttps://www.eatrightstore.org/product-type/pocket-guides/pediatric-weight-management-evidence-based-nutrition-practice-guidelines-quick-reference-toolThis quick-reference 6-page, trifold tool contains graded recommendations for nutritional management of pediatric obesity, such as group or individual sessions, family participation, length of treatment, and treatment settings.
      Pocket Guide to Neonatal Nutrition, 3rd edhttps://www.eatrightstore.org/product-type/books/academy-of-nutrition-and-dietetics-pocket-guide-to-neonatal-nutrition-third-editionThe profession's most respected experts have updated this easy-to-use pocket guide to reflect the latest research in neonatal nutrition, including nutrition assessment of neonates, enteral and parenteral nutrition, medical/surgical conditions, discharge and follow-up, and conversion tables.
      Pocket Guide to Pediatric Nutrition Assessment, 3rd ed.https://www.eatrightstore.org/product-type/pocket-guides/pocket-guide-to-pediatric-nutrition-assessment-third-editionThis pocket guide contains tools, language, and expert guidelines for assessing the nutritional status of infants, children, and adolescents as the first step of the Nutrition Care Process. It contains updated charts of age-specific nutrient needs, predictive equations for estimating energy needs, updated and expanded list of specialized growth charts, and expanded information on anthropometrics and pediatric nutrition-focused physical examination.
      Pocket Guide to Pediatric Weight Management, 2nd ed. (eBook)https://www.eatrightstore.org/product-type/ebooks/pocket-guide-to-pediatric-weight-management-2nd-edition-ebookThis pocket guide addresses the latest guidelines for pediatric weight management and includes assessment tools, intervention strategies, effective counseling approaches, monitoring and evaluation techniques, and prevention plans. It was developed in concert with the Complete Counseling Kit for Pediatric Weight Management.
      Position papershttps://www.eatrightpro.org/practice/position-and-practice-papers/position-papersAcademy Position Papers are an analysis of current facts, data, and research literature and presents the Academy’s stance on an issue. Topics include benchmarks for nutrition in child care; child and adolescent federally funded nutrition assistance programs; and comprehensive nutrition programs and services in schools.
      The Complete Counseling Kit for Pediatric Weight Management (eBook)https://www.eatrightstore.org/product-type/ebooks/the-complete-counseling-kit-for-pediatric-weight-management-ebookThis kit focuses on behavior-change counseling and features strategies, counseling plans, and client educational materials designed for RDNs and other health care providers working with children aged 2 through 18 years and are classified as overweight or obese, and their parents and caregivers.
      The Picky Eater Project: 6 Weeks to Happier, Healthier Family Mealtimeshttps://www.eatrightstore.org/product-type/books/the-picky-eater-projectThis book from the American Academy of Pediatrics is a hybrid parenting, nutrition, and cookbook that assists parents with picky eaters. It focuses on kids’ participation, interactive strategies, kitchen experiments, and delicious kid-friendly recipes.
      Other Resources
      American Academy of Pediatrics (AAP)https://www.aap.org/en-us/Pages/Default.aspxThe AAP is an organization committed to the optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. The AAP provides resources to its members, including journals and publications, career resources, books, guides, and conferences.
      American Society for Parenteral and Enteral Nutrition (ASPEN)http://www.nutritioncare.org/ASPEN is an organization dedicated to improving “patient care by advancing the science and practice of clinical nutrition and metabolism.” ASPEN’s website contains open access clinical guidelines and consensus recommendations relevant to the pediatric population, such as Parenteral Nutrition in Neonates, and the Joint Academy Paper “Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition).”
      • Becker P.
      • Carney L.N.
      • Corkins M.R.
      • et al.
      Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition).
      Other resources include the Preterm Infant Video Series.
      Bright Futures Nutrition Pocket Guide, 3rd Editionhttps://brightfutures.aap.org/materials-and-tools/nutrition-and-pocket-guide/Pages/default.aspxThis pocket guide focuses on health promotion and disease prevention for infants, children, adolescents, and families. It promotes positive attitudes toward nutrition and offers guidance on choosing healthful foods.
      MyPlatehttps://www.myplate.gov/life-stagesThe US Department of Agriculture’s Center for Nutrition Policy and Promotion was established to improve the nutrition and well-being of Americans. One of its core projects is MyPlate, which is a tool to learn how much an individual needs from each food group and is based on the Dietary Guidelines for Americans,
      which includes in the most current revision recommendations for each life stage, including infants and toddlers.
      National WIC Association (NWA)https://www.nwica.org/The NWA is a nonprofit that supports the provider agencies and populations served by the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). NWA provides education, guidance, and support to WIC staff, as well as general advocacy for WIC programs.
      North American Society for Pediatric Gastroenterology, Hepatology & Nutrition (NASPGHAN)https://naspghan.org/NASPGHAN’s mission is to “be a world leader in research, education, clinical practice and advocacy for pediatric gastroenterology, hepatology, and nutrition in health and disease.” It provides resources such as journals, reports, a council for pediatric nutrition professionals, e-mail bulletins, and annual symposium.
      Nutrition by agehttps://www.nutrition.gov/topics/nutrition-ageNutrition.gov offers information to help make healthful eating choices. This website provides resources on nutrition and health for every stage of life, including infants, toddlers, children, and teens.
      MedlinePlus Child Nutritionhttps://medlineplus.gov/childnutrition.htmlThis MedlinePlus website provides information about child nutrition. It contains resources such as statistics and research, journal articles, patient handouts, and links to other helpful websites.
      American Heart Association Healthy Kidshttps://www.heart.org/HEARTORG/HealthyLiving/HeathyKids/Healthy-Kids_UCM_304156_SubHomePage.jspHealthy Kids is a component of the American Heart Association and aims to help kids and families live heart-healthy lives. This website provides resources on topics such as childhood obesity, simple cooking for kids, and healthy habits.

      Training and Continuing Education

      The Accreditation Council for Education in Nutrition and Dietetics–accredited programs that prepare students to become RDNs generally include some pediatrics and related content,
      2022 Standards and Templates. Accreditation Council for Education in Nutrition and Dietetics.
      but additional training and experience are needed for many pediatric RDN positions. Clinical pediatric RDN positions are often not entry-level positions, and formal training programs and mentorships, as well as informal mentoring, are typically needed.
      In addition, ongoing continuing education is needed to keep pediatric RDNs’ knowledge current. The Pediatric Nutrition Practice Group (https://www.pnpg.org/home) offers many resources and professional education opportunities, including a symposia, newsletter, webinars, practice tools, library, and mentoring program.

      Certification

      There are 2 CDR specialist credentials in pediatric nutrition: Board Certification as a Specialist in Pediatric Nutrition (CSP) and Board Certification as a Specialist in Pediatric Critical Care Nutrition (CSPCC). CSPs work with children (neonates to 21 years of age) in a variety of settings. CSPCCs provide medical nutrition therapy for critically ill infants, children, and adolescents. Both credentials require documentation of at least 2,000 hours of practice experience in the specialty (pediatric nutrition or pediatric critical care nutrition) to be eligible to sit for the certification examination.
      Specialty Practice Experience: Pediatric Nutrition. Commission on Dietetic Registration.
      ,
      Specialty Practice Experience: Pediatric Critical Care Nutrition. Commission on Dietetic Registration.
      Other certifications or credentials that apply to pediatric RDNs include the International Board Certified Lactation Consultant (IBCLC)
      International Board of Lactation Consultant Examiners.
      and School Nutrition Specialist (SNS).
      SNS Credentialing. School Nutrition Association.

      Academy Revised 2022 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Pediatric Nutrition

      An RDN can use the Academy Revised 2022 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Pediatric Nutrition (see Figures 1 and 2, available at www.jandonline.org, and Figure 3) to:
      • identify the competencies needed to provide pediatric nutrition and dietetics care and services;
      • self-evaluate whether they have the appropriate knowledge, skills, and judgment to provide safe, effective, and quality pediatric nutrition and dietetics 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 pediatric nutrition and dietetics practice;
      • provide a foundation for public and professional accountability in pediatric nutrition and dietetics care and services;
      • support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of pediatric nutrition and dietetics services and resources;
      • enhance professional identity and skill in communicating the nature of pediatric nutrition and dietetics care and services;
      • guide the development of pediatric nutrition and dietetics–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 pediatric nutrition and dietetics, 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, begin at the competent level when practicing in a new setting or new focus area of practice. An RDN who practices pediatric nutrition at the competent level has learned the principles that underpin this focus area, is developing knowledge and skills, and is gaining experience for safe and effective pediatric nutrition practice. This RDN, whether new to the profession or an experienced RDN, has a breadth of knowledge in nutrition and dietetics and may even have proficient or expert knowledge/practice in another focus area (eg, an RDN working in a small community hospital with a pediatric unit that opens when a pediatric patient is admitted). However, the RDN new to the focus area of pediatric nutrition must accept the challenge of becoming familiar with the body of knowledge, practice guidelines, and relevant resources to support and ensure quality pediatric nutrition–related practice.
      At the proficient level, an RDN has developed a more in-depth understanding of pediatric nutrition 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 to address unique situations (eg, age, ability to participate in care and the nutrition care plan, physical maturation, and/or environment). For example, while an RDN at the competent level could use energy needs to estimate recommended carbohydrate intake for a 5-year old with type 1 diabetes, the RDN at the proficient level would be able to help a parent adjust recommendations to accommodate foods eaten at a birthday party. The RDN at the proficient level may be working towards or possess specialist credentials (eg, CSP and/or CSPCC).
      At the expert level, an RDN uses highly developed clinical and technical knowledge and skills and has a deep and nuanced understanding of pediatric nutrition and its relationship to related fields. RDNs at the expert level of pediatric practice draw on their extensive experience to advance pediatric nutrition and dietetics practice itself and through connections and collaborations with other fields and disciplines. Expert RDNs often have considerable autonomy in practice. They not only develop and implement pediatric nutrition and dietetics services; they also manage, drive, and direct clinical care; conduct and collaborate in research and advocacy; accept organization leadership roles; engage in scholarly work; guide interprofessional teams; provide specialty rotations and train fellows; and lead the advancement of pediatric nutrition and dietetics practice.
      Indicators for the SOP and SOPP for RDNs in Pediatric Nutrition 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). Within the SOP and SOPP for RDNs in Pediatric Nutrition, 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.
      An “X” in the proficient column indicates that an RDN who performs at this level has a deeper understanding of pediatric nutrition and dietetics and has the ability to modify or guide therapy to meet the needs of patients/clients in various situations.
      An “X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of pediatric nutrition and dietetics 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 ) 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 apply across all 3 levels. Indicators not in boldface type were developed for this focus area and are intended to highlight different activities at the competent, proficient, and expert levels in pediatric nutrition. An individual’s practice in pediatric nutrition would likely include indicators within all 3 levels (competent, proficient, and expert) as roles and responsibilities vary among practice settings. Minimally, RDNs working in pediatrics to any degree should be at the competent level with RDNs specializing in pediatrics advancing from competent to proficient and expert levels. 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 Pediatric Nutrition at determined intervals to evaluate their individual focus area knowledge, skill, and competence. Routine 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 pediatric nutrition 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 (step 1), which is a digital tool that assists practitioners in creating an education learning plan.
      Competency plan builder instructions. Commission on Dietetic Registration.
      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 over 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 https://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. RDNs are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience.
      • Peregrin T.
      The ethics of competence, a self-assessment is key.
      RDNs should collaborate with other RDNs in pediatric nutrition as learning opportunities and to promote consistency in practice and performance and continuous quality improvement. See Figure 6 for examples of how RDNs in different roles, at different levels of practice, may use the SOP and SOPP in Pediatric Nutrition.
      Figure 6Role examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Pediatric Nutrition.
      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 pediatric nutrition care and services.
      Community hospital outpatient practitionerAn RDN who provides nutrition services in the community hospital’s outpatient clinic and provides medical nutrition therapy services to adults, adolescents, and children with a variety of medical conditions. The RDN purposely seeks out continuing-education opportunities that address pediatrics-related issues, as this is an area of limited background. The RDN refers to the SOP and SOPP in Pediatric Nutrition and other applicable focus area standards for self-assessment to identify areas for knowledge and skill development and to identify resources.
      Pediatric hospital inpatient and outpatient practitionerAn RDN, Certified Specialist in Pediatric Nutrition (CSP) provides care to pediatric patients as a member of the endocrine clinic team. The RDN, CSP periodically refers to the SOP and SOPP in Pediatric Nutrition and other relevant focus area standards, such as Nutrition Support and Diabetes Care, for self-assessment, to identify resources and areas for continuing education to advance their practice. The RDN, CSP's ongoing continuing education activities (eg, literature reviews, webinars, and professional education conferences) enable effective participation in interprofessional team decision making, contributions to treatment and education plans, and facilitation of referrals to community care providers and programs.
      Neonatal intensive care unit (NICU) clinical practitionerAn experienced hospital pediatric RDN began working in a level 3 NICU. The RDN uses the SOP and SOPP in Pediatric Nutrition to identify resources and perform self-assessment and identify knowledge and skills to enhance and advance their practice. Specific activities include obtaining the Certified Specialist in Pediatric Critical Care (CSPCC) credential and networking with other NICU RDNs. Collaboration with the NICU’s interprofessional team members led to the development of a task force to address issues related to feeding, nutrition, and formula preparation, enhancing and advancing the unit’s practice.
      Clinical nutrition manager (CNM)A CNM in an academic medical center that serves adult and pediatric patients oversees RDNs providing care and services to a diverse inpatient and outpatient population. The CNM uses the focus area SOP and SOPP (eg, Pediatric Nutrition, Diabetes Care, Nutrition Support, and Nephrology Nutrition) as resources for developing a job ladder and competency assessment tools, to work with staff RDNs on self-assessment and identification of knowledge and skills to enhance and advance practice, and to identify resources to support practice and department processes.
      Public health or community nutrition practitionerAn RDN hired to work in a Special Supplemental Nutrition Program for Women Infants and Children (WIC) clinic notes that the clinic regularly serves clients for whom specialized infant formulas are ordered or supports the client’s use of human milk feeding. The RDN uses the SOP and SOPP in Pediatric Nutrition for self-assessment and to identify resources to increase knowledge and skills to effectively provide care to this population. After reviewing resources, including those available from the Pediatric Nutrition Practice Group, the RDN reached out to other RDNs who provided care for several of the clients when they were hospitalized at the children’s hospital to review the discharge plan of care. The RDN uses information gained to evaluate current status, determine need for adjustments to formula volume to support growth when indicated, and to identify when to communicate with the referring pediatrician/medical provider for formula adjustments or when the client needs a higher level of care than the WIC clinic can provide.
      School nutrition practitionerAn RDN employed by a school district participating in the federal Child Nutrition Program reviews requests by health care providers for special diets and related accommodations (eg, the need for snacks for child with type 1 diabetes). The RDN reviews the SOP and SOPP in Pediatric Nutrition and other applicable focus area Standards (eg, Diabetes Care, Intellectual and Developmental Disabilities). The RDN uses the SOP and SOPP for self-assessment to identify areas to pursue additional knowledge and training, which includes networking with hospital and clinical practitioners who have experience with the specific conditions as well as other school nutrition professionals. The RDN uses the information gained to expand resources and assist school nutrition directors, administrators, nurses, and teachers in implementing the necessary accommodations.
      a For each role, the RDN updates their professional development plan to include applicable essential practice competencies for pediatric nutrition care and services.
      Some indicators in the SOP and SOPP for RDNs in Pediatric Nutrition do not have an expert level of practice identified (ie, an indicator is identified as proficient). It remains the consensus of the content experts that the distinctions in levels of practice are subtle, captured in the knowledge, experience, and wisdom 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 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 develop. 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 pediatric nutrition 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, https://www.pnpg.org/awards).

      Future Directions

      The SOP and SOPP for RDNs in Pediatric Nutrition are dynamic documents. Revisions reflect 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, efficient, equitable, and quality practice in pediatric nutrition remains an expectation of each revision to serve tomorrow's practitioners and their patients, clients, and customers.

      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 Pediatric Nutrition are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by RDNs who provide care to pediatric populations to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, efficient, 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 pediatric nutrition 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, as well as advances in pediatric nutrition 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 and the Pediatric Nutrition Practice Group, 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 to Dana M. Vieselmeyer, MPH, RDN, LD, who reviewed these standards, and to the Academy staff, in particular, Carol Gilmore, MS, RDN, LD, FADA, FAND; Dana Buelsing Sowards, 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 SOPP. Additional thanks go to the Pediatric Nutrition Practice Group’s Executive Committee. Finally, the authors acknowledge the significant influence of RDNs currently practicing in pediatric nutrition fields in the shaping of these standards.

      Author Contributions

      Both authors 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 Pediatric Nutrition. Note: The terms patient, client, caregiver, family, individual, person, customer, group, and 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 Pediatric Nutrition

      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 screening data or screens for nutrition risk (eg, malnutrition, nutrient deficits, food security) using evidence-based screening toolsXXX
      1.1BIdentifies chronic and acute conditions that affect nutrient needs, nutrient intake, growth, and eating- and food-related behaviors; seeks additional information if condition is not typicalXXX
      1.1CConsiders psychosocial factors or issues, including family and significant others, social support, mental health issuesXXX
      1.1DAttributes nutrition-related consequences (eg, growth, eating- and food-related behaviors) to specific conditions, including the process/progress of disease (eg, metabolic acidosis causing poor appetite, swallow dysfunction preventing adequate oral intake)XX
      1.1EAnticipates potential problems related to chronic or acute conditionsXX
      1.1FExamines for symptoms of or potential for coexisting disease or nutrition conditions related to present nutrition/disease stateX
      1.2Anthropometric assessment: Assesses anthropometric indicators (eg, height/length, weight, body mass index [BMI], weight-for-length, waist circumference, mid-upper arm circumference, head circumference), comparison to reference data (eg, percentile ranks/z scores), and individual patterns and historyXXX
      1.2AEvaluates growth measurements (eg, weight, height/length, head circumference, weight-for-length or BMI, mid upper arm circumference); compares to appropriate reference data (eg, CDC
      CDC = Centers for Disease Control and Prevention.
      /WHO
      WHO = World Health Organization.
      growth charts, or other standardized growth chart) and growth progress and trends
      XXX
      1.2BIdentifies and considers limitations of reference standards related to age, race, ethnicity, or genderXX
      1.2CIdentifies reference data for use with patients/clients with rare conditions that affect growth expectations (eg, Duchenne muscular dystrophy, Down syndrome, cerebral palsy, Prader-Willi syndrome)XX
      1.2DUses information (eg, patient’s/client’s history, condition) to predict expectations for growth that are different than for the general population as well as the reference population (eg, other individuals with the same rare condition)X
      1.3Biochemical data, medical tests, and procedure assessment: Assesses laboratory profiles (eg, acid–base balance, renal function, endocrine function, inflammatory response, vitamin/mineral indices, lipid profile), medical tests, and procedures (eg, gastrointestinal studies, metabolic rate, swallow studies, bone density studies)XXX
      1.3AAssesses nutrition-related implications of tests, procedures, and biochemical evaluations; seeks additional information if results are not typicalXXX
      1.3BAssesses results of diagnostic tests, procedures, and evaluations; identifies appropriate laboratory testing for differentiating specific nutrition-related diseases and conditionsXX
      1.3CApplies 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
      1.4AAssesses physical findings and incorporates the effects of health condition(s) and outside influencesXX
      1.4BDetermines need for further testing, including appropriateness of tests and effects on the individualX
      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, including impact of food preferences, food allergies, and intolerancesXXX
      1.5A1Compares to established guidelines, given developmental stage and physical activity levelXXX
      1.5A2Incorporates the effects of health condition(s) and outside influences on dietary intake and estimated needs and feeding modality; seeks additional related information (eg, types and amounts of foods offered, timing of meals/snacks/feedings, feeding-related behaviors), including input from patient/client/caregiver
      Patient/client/caregiver: The term patient/client/caregiver is used throughout the document to refer to the individuals ages 0 to 21 years and those who provide care to them. In some instances, terms such as legal guardian and advocate12 may apply as well. Each situation is unique and there are likely others involved in the lives and care of infants, children, and adolescents.
      XX
      1.5A3Uses health condition history and present status to identify factors that might influence the plan (eg, feeding skill level, access to resources, and expected outcomes to encourage the development of feeding/eating skills, as appropriate)X
      1.5A4Investigates nonapparent influences on appetite, intake, and preferences (eg, environmental, social, mental health, trauma, or other adverse childhood experiences)X
      1.5BFood and nutrient administration including current and previous diets and diet prescriptions and food modifications, eating environment, and enteral and parenteral nutrition administrationXXX
      1.5B1Assesses appropriateness of diet prescription based on meal-time observation(s), medical information, patient/client/caregiver report(s), previous nutrition diagnosis(es), diet history, food preferences, and changes in appetite or usual intakeXXX
      1.5B2Evaluates influence of eating environment, access, and cultural influences or differences (eg, location, atmosphere, family/caregiver) on intakeXXX
      1.5B3Identifies trends that could lead (or have led to) changes in appetite or usual intake, including changes that are part of the disease process, treatment, comorbid conditionsXX
      1.5CMedication and dietary supplement use, including prescription and over-the-counter medications, and integrative and functional medicine productsXXX
      1.5C1Considers the safety and efficacy of over-the-counter medications, herbal medications, and dietary supplements, including interactions with medications and other nutrientsXXX
      1.5C2Assesses nutrition-related adverse effects of medications used long-term (including alterations in absorption, metabolism, or excretion of nutrients)XX
      1.5C3Assesses, as a part of an interprofessional team, the need to add or discontinue medications and/or dietary supplements, or adjust the dose and timing of medicationsXX
      1.5C4Evaluates potential interactions between prescription, over-the-counter, and other medications and dietary supplements that are being used by the patient/clientX
      1.5DKnowledge, beliefs, and attitudes (eg, understanding of nutrition-related concepts, emotions about food/nutrition/health, body image, readiness to change nutrition- or health-related behaviors, and activities and actions influencing achievement of nutrition-related goals)XXX
      1.5D1Assesses patient’s/client’s/caregiver’s understanding of health condition(s) and nutrition-related effects and implicationsXXX
      1.5D2Identifies patient’s/client’s/caregiver’s goals for nutrition interventionXXX
      1.5D3Evaluates effectiveness of previous nutrition interventions, strategies, methods, motivators, and barriers; progress toward established goals; and level of understanding of nutrition-related issuesXXX
      1.5D4Evaluates patient’s/client’s/caregiver’s ability to identify evidence-based nutrition information in the media and popular literatureXXX
      1.5D5Evaluates nonapparent influences (eg, social networks, culture, ethnicity, and religion) that can affect potential for behavior change or achievement of nutrition-related goalsXX
      1.5D6Applies different style/interaction methods as situations present to facilitate successful nutrition careX
      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 access to and use of community resources (eg, safe food and water, food preparation, and storage facilities)XXX
      1.5E2Identifies emergency/disaster preparedness plan of patient/client/caregiver (eg, availability of food, water, enteral nutrition/tube feeding supplies, medication)XXX
      1.5E3Identifies potential barriers to adequate food access (eg, living conditions, transportation, finances, language, and cultural differences)XX
      1.5E4Investigates to identify potential or subtle barriers that interfere with food access, selection, or preparation (eg, patient’s/client’s/caregiver’s risk or history of depression, anxiety, disordered eating, and substance abuse; family dynamics; changes to living situation; cultural- or language-related barriers)X
      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 self-care skills and behaviors, considering developmental appropriatenessXXX
      1.5F2Assesses health literacy and numeracy (ie, ability to use health information and math skills to make appropriate health-related decisions)XXX
      1.5F3Identifies behavioral mediators (or antecedents) related to dietary intake (eg, patient/client/caregiver attitudes, self-efficacy, knowledge, intentions, motivations, readiness to change, perceived social support)XX
      1.5GOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial, adverse childhood experiences, and social determinants of health)XXX
      1.5G1Identifies and uses evidenced-based quality of life surveys (eg, Pediatric Quality of Life Inventory https://www.pedsql.org/about_pedsql.html)XX
      1.6Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, BMI, and desired growth patternsXXX
      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 and disease state)XXX
      1.6A1Uses understanding of patient’s/client’s history, condition, or other issues to individualize expectations and deviate from established reference standardsXX
      1.6A2Develops recommendations and guidelines for individualizing expectations and deviating from established reference standards on an organization levelX
      1.7Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity trainingXXX
      1.7ACompares usual activity level with physical activity guidelines (https://health.gov/our-work/physical-activity/current-guidelines)XXX
      1.7BAssesses factors influencing access to physical activity (eg, environmental safety, walkability of neighborhood, proximity to parks/green space, access to physical activity facilities/programs)XXX
      1.7CEvaluates factors limiting physical activity (eg, vision or mobility impairments, seizure disorders, sensory issues, hypotonia, medical equipment interfering with movement)XXX
      1.7DAssesses effect of planned treatment on usual activity level, ability to perform ADLs, and achievement of developmental milestonesXX
      1.7EEvaluates access to resources in context of patient’s/client’s/family’s habits and communityXX
      1.8Collects data and/or reviews data obtained and/or documented by the nutrition and dietetics technician, registered (NDTR), other health care practitioner(s), patient/client/caregiver, or staff for factors that affect nutrition and health statusXXX
      1.9Uses collected data to determine nutrition diagnosesXXX
      1.9AConsiders potential nutrition diagnoses and identifies factors that may affect interventionsXX
      1.10Documents and communicates:
      1.10ADate and time of assessmentXXX
      1.10BPertinent data (eg, medical, social, behavioral)XXX
      1.10CComparison with appropriate standardsXXX
      1.10DPatient/client/caregiver/population perceptions, values and motivation related to presenting problemsXXX
      1.10EChanges in patient/client/caregiver/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 and prioritizes the diagnoses, as appropriate.

      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
      2.1ACorrectly diagnoses nutrition problems by systematically evaluating findings using critical thinking, and experience with the populationXXX
      2.1BEvaluates multiple factors and complex data (eg, pre-existing conditions, impact of therapies and interventions, and clinical status) in the determination of the etiologyXX
      2.1CApplies clinical knowledge and experience to identify nutrition diagnoses for individuals with complex nutrition problemsX
      2.2Prioritizes the nutrition problem(s)/diagnosis(es) based on severity, safety, patient/client/family needs and preferences, ethical considerations, likelihood that nutrition intervention/plan of care will influence the problem, discharge/transitions of care needs, and patient/client/caregiver prioritiesXXX
      2.2AUnderstands the importance of considering the patient/client/ caregiver role in decision makingXXX
      2.2BUses protocols and guidelines to prioritize nutrition diagnoses in order of importance or urgency; seeks additional information, input if neededXXX
      2.2CUses experience in addition to protocols and guidelines to prioritize nutrition diagnoses in order of importanceXX
      2.2DUses experience and clinical judgment to know when to deviate from protocols/guidelines when prioritizing an individual’s nutrition diagnoses/problemsX
      2.3Communicates the nutrition diagnosis(es) to patients/clients/caregivers, community, family members, or other health care professionals when possible and appropriateXXX
      2.3AParticipates in developing patient/client/caregiver communication protocols and pathways to meet the organization’s/program’s standards and the workflow of the setting, when applicableXX
      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] statements or Assessment [A], Diagnosis [D], Intervention [I], Monitoring [M], and Evaluation [E] [ADIME] statement)XXX
      2.5Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      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 reviewing the nutrition diagnoses, conferring with the patient/client and others, and reviewing practice guidelines, protocols, and policies. This information is used to set goals and define 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
      3.1ACollaborates with patient/client/caregiver to determine priorities, goals, preferences, and expected outcomes that will inform prioritization of intervention/plan of careXXX
      Considers and evaluates:
      3.1BRisk for acute or chronic health complications related to implementing (or not implementing) intervention, including effects on existing health conditionsXXX
      3.1CReadiness to implement intervention, including access to needed resources and supportXXX
      3.1DPhysical, cognitive, developmental, and behavioral readiness for interventionXX
      3.1ERole of emerging therapies (eg, proton therapy that interferes with feeding)XX
      3.1FPotential effects on other interventions (eg, how nutrition intervention may minimize treatment-related adverse effects, treatment delays, and the need for emergency department visits or hospital admission/readmission)X
      3.1GRole of nontraditional interventions (eg, use of medical cannabinoid products)X
      3.2Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines, and best practices (see Figure 4)XXX
      3.2AAdjusts application of guidelines and protocols based on the individual patient’s/client’s situationXX
      3.2BRecognizes when it is appropriate and safe to significantly deviate from established guidelines and adjust a patient’s/client’s intervention planX
      3.3Refers to policies and procedures, protocols, standards of care, and program standardsXXX
      3.4Collaborates with patient/client/caregiver/population, 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, dietetic technicians, physician assistants, nurse practitioners, pharmacists, psychologists, social workers, lactation consultants, occupational and physical therapists, speech language pathologists, behavior therapists/analysts, educators, and family resource coordinators), depending on the needs of the patient/client/family. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team, and other health care professionals
      XXX
      3.4ACollaborates with or refers to other members of the interprofessional team (eg, patient/client/caregiver, social worker, occupational, physical, or speech therapist, lactation consultant, RDN with expertise in other specialty field)XXX
      3.4BRecognizes specific knowledge and skills of other providers, and collaborates to provide comprehensive careXX
      3.4CRecognizes potential nutrition implications of other therapies (eg, food used as a reward, food used therapeutically [eg, oral-motor skills])XX
      3.4DOrganizes and leads communication with the patient/client/ caregiver; provides case management in collaboration with the interprofessional teamX
      3.4EWorks with other disciplines to set overarching goals when therapies overlap (eg, selects foods for focus of feeding therapy to address oral-motor and nutrient-specific concerns)X
      3.5Works with patient/client/caregiver/population to identify goals, preferences, discharge/transitions of care needs, plan of care, and expected outcomesXXX
      3.5AConsiders health care and resource utilization (eg, length of stay, need for home therapies, hospital readmission, community nutrition resources [eg, Special Supplemental Nutrition Program for Women, Infants, and Children], early intervention)XX
      3.6Develops the nutrition prescription and establishes measurable patient-/client-focused goals to be accomplishedXXX
      3.6ADevelops an intervention plan that considers and/or addresses current issues (eg, disease state, activity level, medications interactions and/or adverse effects)XXX
      3.6BDevelops a patient/client and/or caregiver education plan or program to address current needsXXX
      3.6CDevelops an intervention plan that considers and/or addresses anticipated changes (eg, introduction of complementary foods, transition from early intervention to school program) and incorporates patient/family/caregiver in developing and implementing the planXX
      3.6DIntegrates information, knowledge, and critical thinking to address complex and/or subtle issuesX
      3.7Defines time and frequency of care, including intensity, duration, and follow-upXXX
      3.7AConsiders expected changes in nutrition status, functional ability, and progress toward nutrition outcomesXX
      3.7BConsiders pending medical interventions, confirmation of suspected medical diagnoses that are influenced by or may influence nutrition statusX
      3.8Uses standardized terminology for describing interventionsXXX
      3.9Identifies resources and referrals as neededXXX
      3.9AFacilitates referral(s) for other services using existing intra- and interorganization networks (eg, contacts primary care provider to suggest referral for feeding evaluation; recommends lactation consult)XX
      3.9BPromotes referrals to other interprofessional team members by understanding and communicating roles of other disciplines, rationale and benefits of additional services to other team members, including patient/client/family/caregiverXX
      3.9CCoordinates referral(s) for other services (eg, makes referral to early intervention program, lactation consultant, feeding team)X
      3.9DEstablishes and maintains interagency networks based on patient’s/client’s or caregiver needs; links nutrition and other servicesX
      Implements the Nutrition Intervention/Plan of Care:
      3.10Collaborates with colleagues, interprofessional team, and other health care professionalsXXX
      3.10AFacilitates and fosters active communication, learning, partnerships, and collaboration with the interprofessional team and others as appropriateXX
      3.10BIdentifies and seeks out opportunities for interprofessional and interorganizational collaboration, specific to the patient's/client’s/ caregiver’s needsX
      3.11Communicates and coordinates the nutrition intervention/plan of careXXX
      3.11ACommunicates nutrition care plan and ensures transfer of nutrition-related data between care settings as needed and understanding by interprofessional team members, including patient/client/familyXXX
      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.6,7 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.9,10
      -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, enteral and parenteral nutrition, intravenous fluid infusions, laboratory tests, medications, and education and counseling)XXX
      3.12A1iRecommends nutrition-related orders (eg, diet, human milk, formula and modular products, medical food, dietary supplements)XXX
      3.12A1iiModifies orders to individualize the nutrition intervention/plan of care, consistent with approved clinical privileges and organization policyXX
      3.12A1iiiInitiates orders to individualize the nutrition intervention/plan of care, consistent with approved clinical privileges and organization policyX
      3.12A2Manages nutrition support therapies (eg, formula selection, rate adjustments, addition of designated medications and vitamin/mineral supplements to parenteral nutrition solutions or supplemental water for enteral nutrition)XXX
      3.12A2iReviews care plan with the interprofessional team at regular intervals to provide safe, effective, and evidence-based nutrition support therapyXXX
      3.12A3Initiates and performs nutrition-related services (eg, inserting and monitoring nasoenteric feeding tubes, and indirect calorimetry measurements, or other permitted services)XXX
      3.12A3iRecommends and/or interprets results of tests used in evaluating nutritional status, such as indirect calorimetry for measuring energy expenditure in collaboration with respiratory therapistXX
      3.12A3iiOrders and/or performs nutrition-related services consistent with specialized training and clinical privileges (eg, inserting nasoenteric feeding tubes or bedside swallow screenings with recommendation for swallow study or referral to speech pathologist, if needed)X
      3.12BIdentifies nutrition education tools and approaches that are appropriate to the patient’s/client’s/caregiver’s learning style, method of communication, literacy and numeracy level, language, culture, and beliefsXXX
      3.12CUses critical thinking and synthesis skills for combining multiple intervention approaches as appropriate and adapts general nutrition education tools to individualized learning style and method of communicationXX
      3.12DTailors nutrition education approach to meet the needs of the patient/client/caregiver (eg, considers age, literacy, numeracy, language, culture, learning style, and methods of communication)XX
      3.12EDraws on experiential knowledge and current body of advanced knowledge about the patient/client population to individualize the strategy for complex and dynamic situationsX
      3.12FUses and individualizes appropriate behavior change theories (eg, motivational interviewing, behavior modification, modeling)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 consistent with role and responsibilitiesXXX
      3.13BTrains qualified support personnel in specific tasks related to nutrition monitoring (eg, obtaining data from intake and output forms, completing intake analysis incorporating oral, enteral and/or parenteral nutrition)XX
      3.13CProvides formal feedback/evaluation of pediatrics-specific skills performed by support personnelX
      3.14Continues data collectionXXX
      3.14AUses data to continue to inform and modify intervention planXXX
      3.15Documents:
      3.15ADate and timeXXX
      3.15BSpecific and measurable treatment goals and expected outcomesXXX
      3.15CRecommended interventionsXXX
      3.15DPatient/client/caregiver/community receptivenessXXX
      3.15EReferrals made and resources usedXXX
      3.15FPatient/client/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/caregiver/population and health care and other providers 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 adjusts the intervention/plan of care as needed.
      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:XXX
      4.1AAssesses patient/client/caregiver/population understanding and compliance with nutrition intervention/plan of careXXX
      4.1A1Verifies understanding of nutrition intervention by having the patient/client/caregiver verbalize and/or demonstrate understanding (eg, describe goals, human milk/formula and/or food choices, demonstrate human milk/formula or food preparation techniques)XXX
      4.1A2Identifies current barriers to understanding that impact the patient’s/client’s/caregiver’s implementation of the nutrition intervention/plan of careXX
      4.1A3Anticipates potential barriers to understanding and/or implementation of nutrition intervention/plan of careX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Recognizes when nutrition intervention/plan of care is not being implemented as prescribedXXX
      4.1B2Evaluates intervention plan implementation considering special situations (eg, holidays, changes to living situation, family, or relationship)XXX
      4.1B3Identifies and addresses underlying and/or dynamic issue(s) preventing the nutrition intervention/plan of care from being implemented as prescribed (eg, restrictions on use of enteral feeding pump during religious observances, frequent procedures interfering with provision of nutrition support)XX
      4.1B4Uses experience and critical thinking to identify alternate approaches or additional resources to ensure that the intervention is implemented as prescribedX
      4.2Measures outcomes:XXX
      4.2ASelects the standardized nutrition care measurable outcome indicator(s)XXX
      4.2A1Considers person-centered outcomes (eg, quality of life, physical well-being, anthropometric and laboratory data, clinical status, and patient’s/client’s/family’s/caregiver’s satisfaction)XXX
      4.2A2Uses critical thinking skills to adapt/create outcome measures when standardized measures do not apply to the patient/clientXX
      4.2BIdentifies positive or negative outcomes, including impact on potential needs for discharge/transitions of careXXX
      4.2B1Evaluates intended effects and potential adverse effects related to complex problems and intervention (eg, monitoring appropriateness of growth and maintenance of nutrition and fluid status during transition from enteral to thickened oral feedings)XX
      4.2B2Contributes to the identification of benchmarks to document patient’s/client’s nutritional status for timely documentation/review as a part of an interprofessional teamXX
      4.2B3Uses knowledge of the population, experience, and critical thinking in evaluating complex changes in condition, impact of interventions, and other factors on achievement of outcomesX
      4.2CExplores patient/client/caregiver perception of success related to the designated outcome indicatorsXX
      4.2DEvaluates patient’s/client’s variance from planned outcomes and the established guideline indicators; incorporates knowledge into future individualized treatment recommendationsX
      4.3Evaluates outcomes:XXX
      4.3ACompares monitoring data with nutrition prescription and established goals or reference standardXXX
      4.3A1Monitors and analyzes clinical and other data relative to achieving patient/client outcomesXXX
      4.3A2Monitors and analyzes clinical data, other outcomes (eg, serial and trended laboratory test results) in complex situationsXX
      4.3A3Selects an appropriate data set/benchmark for the individual (eg, WHO Child Growth Standards—weight velocity tables, Cystic Fibrosis Foundation consensus guidelines, NKF-KDOQI
      NKF-KDOQI = National Kidney Foundation-Kidney Disease Outcome Quality Initiative.
      clinical practice guidelines)
      XX
      4.3A4Analyzes and understands data based on experience, clinical judgment, and identifies criteria to which the data are comparedXX
      4.3A5Defines and manages nutrition-related issues in the context of the patient's/client’s total care (eg, completes a comprehensive analysis of the indicators and correlates one problem to another)X
      4.3BEvaluates impact of the sum of all interventions on overall patient/client/population health outcomes and goalsXXX
      4.3B1Uses clinical judgment and experience with pediatric population to analyze the impact of all interventions on patient’s/client’s health outcomes and quality of lifeXX
      4.3CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.3C1Uses information from interprofessional team, including patient/client/caregiver, to assess progress toward nutrition goals and identify barriersXXX
      4.3C2Assesses underlying factors interfering with progress (eg, lack of access to services, food insecurity, communication difficulties), and analyzes their impact on future treatment recommendationsXX
      4.3C3Considers patient’s/client’s/caregiver’s stage of behavior change and learning style to evaluate need to revise nutrition intervention and plan of careX
      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
      4.3D1Uses multiple data sources to assess progress (eg, NFPE, laboratory and other clinical data, changes in body weight/body composition, pertinent medications/dietary supplements) relative to effectiveness of the care planXX
      4.3D2Identifies complex underlying problems beyond the scope of nutrition that are interfering with the intervention and recommends appropriate adjustments to the plan of careX
      4.3ESupports conclusions with evidenceXXX
      4.3E1Clearly identifies subjective and objective evidence to support conclusions (eg, documents nutrition prescription is being followed or barriers interfering with receipt of full nutrition prescription)XXX
      4.4Adjusts nutrition intervention/plan of care strategies, if needed, in collaboration with patient/client/caregiver/population/and interprofessional teamXXX
      4.4AImproves or adjusts intervention/plan of care strategies based on outcomes data, trends, best practices, and comparative standards (eg, recommends or modifies diet or nutrition-related orders, addresses barriers to implementing intervention)XXX
      4.4BMakes adjustments in complicated situations (eg, multiple or complex medical conditions, complex social situations, lack of or incomplete information), such as modifying nutrition support recommendations or tailoring tools and methods to better reflect developmental age, environmental factorsXX
      4.4CAnticipates need for additional resources (eg, sources of equipment or nutrition products, avenues for therapy) to fulfill the nutrition prescriptionXX
      4.4DAlters or tailors tools and methods with the patient/client/caregiver based on emerging information/response to promote the desired outcomeXX
      4.4EMakes adjustments in unpredictable and dynamic situations (eg, conditions for which outcomes are not well-known or there is a limited evidence base for interventions; situations that have the potential to change rapidly)X
      4.4FLeads in analysis of data and discussions with interprofessional team when outcomes are not achieved to revise the plan and/or interventions (eg, lead development of enteral nutrition pathway)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, patient’s/client’s/family’s/caregiver’s perspective on plan, problems, and progressXXX
      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/caregiver/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-/caregiver-/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, 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 CDC = Centers for Disease Control and Prevention.
      b WHO = World Health Organization.
      c Patient/client/caregiver: The term patient/client/caregiver is used throughout the document to refer to the individuals ages 0 to 21 years and those who provide care to them. In some instances, terms such as legal guardian and advocate
      The Joint Commission
      Glossary.
      may apply as well. Each situation is unique and there are likely others involved in the lives and care of infants, children, and adolescents.
      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, dietetic technicians, physician assistants, nurse practitioners, pharmacists, psychologists, social workers, lactation consultants, occupational and physical therapists, speech language pathologists, behavior therapists/analysts, educators, and family resource coordinators), depending on the needs of the patient/client/family. Interprofessional could also mean interdisciplinary or multidisciplinary.
      e 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.
      f NKF-KDOQI = National Kidney Foundation-Kidney Disease Outcome Quality Initiative.
      Figure 2Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Pediatric Nutrition. Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean client, patient, family, participant, consumer, or any individual, group, or organization to which the RDN provides service. The term organization could also mean department, program, or unit.
      Standards of Professional Performance for Registered Dietitian Nutritionists in Pediatric Nutrition

      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 (eg, state licensure or certification laws, federal or state regulations, and payment policies) as related to their area(s) of practiceXXX
      1.1AEnsures that organization/institution policies and practices related to nutrition and dietetics, including telehealth, complies with applicable laws, regulations, and reimbursement programsXX
      1.2Performs within individual and statutory scope of practice and applicable laws, regulations, and accreditation standardsXXX
      1.2AEnsures practice is consistent with additional credentialing requirements (eg, Board Certified Specialist in Pediatric Nutrition [CSP] and/or Pediatric Critical Care Nutrition [CSPCC], Advanced Practitioner Certification in Clinical Nutrition [RDN-AP], International Board Certified Lactation Consultant [IBCLC], Certified Lactation Counselor [CLC], Certified Nutrition Support Clinician [CNSC], Certified Diabetes Care and Education Specialist [CDCES])XX
      1.3Adheres to sound business and ethical billing practices applicable to the role and settingXXX
      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, Healthcare Cost and Utilization Project database) to improve the quality of services provided and to enhance customer-centered servicesXXX
      1.4AUses nationally standardized and consensus-based pediatric nutrition guidelines (eg, Academy EAL,
      EAL = Academy Evidence Analysis Library (www.andeal.org/).
      American Academy of Pediatrics [AAP] Clinical Practice Guidelines, Bright Futures, ASPEN
      ASPEN = American Society for Parenteral and Enteral Nutrition (www.nutritioncare.org).
      Pediatric Guidelines, and Southeast Regional Newborn Collaborative Nutrition Management Guidelines for Phenylketonuria) in design and evaluation of nutrition care and services
      XXX
      1.4BParticipates in hospital, agency, or institution quality assurance and performance improvement for pediatric nutrition care and servicesXX
      1.4CAnticipates changes to local, state, and national quality initiatives, and leads efforts to support pediatric nutrition care and related servicesX
      1.4DLeads program’s 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; nutrition and dietetics technicians; physician assistants; nurse practitioners; pharmacists; psychologists; social workers; lactation consultants; occupational and physical therapists; speech language pathologists; behavior analysts/therapists; educators; and family resource coordinators), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team meetings and promotes use of national consensus-based standards and measures in performance monitoring processes
      X
      1.5Uses a systematic performance improvement model that is based on practice knowledge, evidence, research, and science for delivery of the highest quality servicesXXX
      1.5AUses the organization/department performance improvement process to collect data and measure performance against desired outcomes; obtains training as neededXXX
      1.5BMentors members of the interprofessional team on performance improvement model(s) and leads performance improvement initiativesXX
      1.5CDevelops strategies for quality and process improvement tailored to the needs of the organization and its target audience (eg, identifies and/or adapts practice guidelines, skills training, and/or reinforcement)XX
      1.5DLeads the design and evaluation of organization policies and procedures for monitoring and improving pediatric nutrition services (eg, revision of admission nutrition screening process)X
      1.5EProactively recognizes needs, anticipates outcomes and consequences of different approaches, and makes necessary modifications to plans to achieve pediatric nutrition quality outcomesX
      1.5FDevelops 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, family-/person-centeredness, equity, timeliness, and efficiency of practiceXXX
      1.6AInvolves colleagues and others, as applicable, in systematic outcomes managementXXX
      1.6A1Participates in department/program and interprofessional efforts to monitor and improve interventions and outcomesXXX
      1.6A2Prioritizes performance improvement projects based on organization objectives (eg, minimize bias and inequity, maximize reimbursement, regulation and accreditation requirements, achieving core measures)XX
      1.6A3Leads interprofessional efforts to monitor and improve interventions and outcomesX
      1.6BDefines expected outcomesXXX
      1.6B1Identifies quality outcomes and defines targets related to pediatric nutrition through evaluation, benchmarking, and monitoring of environmental trendsXX
      1.6B2Determines desired nutrition-specific outcomes for the patient/client population through direct evaluation, benchmarking (eg, national standards, practice guidelines), and evaluation of environmental trendsX
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6DMeasures quality of services in terms of structure, process, and outcomesXXX
      1.6D1Uses a continuous quality and process improvement approach to collect data and measure use of pediatric nutrition care and services against its outcomes (eg, population served, acuity, clinical risk factors, morbidity, mortality)XXX
      1.6D2Selects criteria and participates in development of tools and processes that capture the needs of diverse populations, accurately measure health outcomes, and recognize and minimize bias and inequityXX
      1.6D3Directs quality measurement processes to evaluate effectiveness of services provided and influence changeX
      1.6D4Conducts 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 program admission process or nutrition assessment using evidence-based screening tools (eg, Screening Tool for the Assessment of Malnutrition in Pediatrics [STAMP], Pediatric Nutritional Risk Score [PNRS]) for the setting and/or populationXX
      1.6E2Uses applicable clinical quality measures to collect and report relevant data (eg, population risk factors, screening timeframes, services provided)XX
      1.6E3Leads or participates in development or revision of organization electronic clinical quality measures to identify and improve care of individuals with or at risk for malnutritionX
      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
      1.6F1Evaluates patient/client and service outcomes data against patient/client population needs, treatment goals, department/program goals, and community impactXX
      1.6GParticipates in, coordinates, or leads program participation in local, regional, or national registries (eg, Cystic Fibrosis [CF] Patient Registry, Vermont Oxford Network [VON], National Institute of Child Health and Human Development [NICHD]Neonatal Research Network) and data warehouses used for tracking, benchmarking, and reporting service outcomesXXX
      1.6G1Participates in registries and data warehouses used for tracking, benchmarking, and reporting service outcomesXXX
      1.6G2Provides training and coordinates participation in registries and data warehouses used for tracking, benchmarking, and reporting service outcomesXX
      1.6G3Provides pediatric- and nutrition-related expertise to national informatics projects (eg, national databases)X
      1.6G4Leads program participation in registries and data warehouses used for tracking, benchmarking, and reporting service outcomes (eg, NICHD Neonatal Research Network, CF Patient Registry, VON)X
      1.6G5Promotes inclusion of RDN-provided nutrition services in local, state, and/or national data registriesX
      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
      1.7AKeeps up to date on potential and actual errors and hazards (eg, food-safety issues, formula specification/formulation changes, formula recalls, drug–food/nutrient and dietary supplement interactions, US Food and Drug Administration import alerts [https://www.fda.gov/industry/actions-enforcement/import-alerts])XXX
      1.7BAnticipates potential for errors (eg, human milk/formula room practices; changes in product formulation resulting in need for new infant formula recipes), and addresses them or alerts administrators, as appropriateXX
      1.7CDevelops policies and procedures, and/or best practices to identify, address, and prevent errors and hazards in the delivery of pediatric nutrition care and services, including formula room practices, product shortagesX
      1.8Compares actual performance to performance goals (ie, Gap Analysis, SWOT [Strengths, Weaknesses, Opportunities, and Threats] Analysis, PDCA [Plan-Do-Check-Act] Cycle, DMAIC [Define, Measure, Analyze, Improve, Control])XXX
      1.8AReports and documents action plan to address identified gaps in care and/or service performanceXXX
      1.8BBenchmarks department/organization performance with national programs and standardsXX
      1.8CLeads interprofessional team in root-cause analysis of persistent barriers impacting achieving desired outcomesX
      1.9Evaluates interventions and workflow process(es) and identifies service and delivery improvementsXXX
      1.9AParticipates in testing interventions and developing action plans to improve nutrition processes and services for the pediatric populationXX
      1.9BUses evaluation data and/or collaborates with interprofessional team to identify program/service improvementsXX
      1.9CGuides the development, testing, and redesign of 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 practice based on measured outcomes and established goals, with guidance from supervisor, team leader, or mentorXXX
      1.10BSystematically reviews nutrition care or services, identifies problem areas, and recommends improvements to practice (eg, adjusts organization’s standards of care)XX
      1.10CLeads or facilitates changes to organization’s practices, policies, and procedures based on measured outcomes and established goals (eg, modifies organization formula preparation procedures in response to identified risks, adjusts staffing model or workflow to accommodate changes to the organization)X
      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; 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
      2.2Integrates 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 (eg, diabetes care, intellectual and developmental disabilities, nutrition support; see www.eatrightpro.org/sop)XXX
      2.2BUses the SOP and SOPP for RDNs in Pediatric Nutrition to assess and update standards of care, organization’s practice guidelinesXX
      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 Pediatric NutritionX
      2.2DUses advanced practice experience and knowledge to define specific activities for levels of practice (competent, proficient, expert) reflecting the SOP and SOPP for RDNs in Pediatric NutritionX
      2.3Demonstrates and documents competence in practice and delivery of customer-centered service(s)XXX
      2.3ADemonstrates pediatric nutrition knowledge, skills, and competence in areas such as medical nutrition therapy, nutrition pharmacology, nutrition pathophysiology, evidence-based practice, counseling, and comorbiditiesXX
      2.3BDocuments examples of expanded professional responsibility (eg, quality assurance and performance improvement, leadership responsibilities, corporate-/system-level role(s), state and/or national advisory board participation)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
      2.4CStrives for an improvement in practice with self and others; is active in defining and positioning the pediatric RDN in team, hospital, or organizationXX
      2.4DDevelops and implements policies and procedures that ensure staff accountability and responsibilityX
      2.5Conducts self-evaluation at regular intervalsXXX
      2.5AIdentifies needs for professional development (ie, compares individual performance with personal goals and best practices)XXX
      2.5BEvaluates level of practice to determine whether additional knowledge, skills, and/or activities are needed to advance practiceXXX
      2.6Designs and implements plans for professional developmentXXX
      2.6ADevelops plan and documents professional development activities in career portfolio consistent with organizational and/or credentialing agency(ies)’ policies and proceduresXXX
      2.6BParticipates in continuing education opportunities relevant to pediatric nutrition and role(s) and responsibilitiesXXX
      2.6CImplements a plan for achieving the knowledge, skills, and experience needed to qualify for or maintain certification(s) (eg, CSP, CSPCC, RDN-AP) to support role(s) and responsibilitiesXX
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7ARecognizes strengths and limitations of current research and practice guidelines (eg, Academy EAL, AAP) when making recommendations; seeks assistance if neededXXX
      2.7BEvaluates practice for consistency with current research and practice guidelines in pediatric nutrition and other applicable areasXXX
      2.7CFamiliarizes self with publications related to pediatric nutritionXXX
      2.7DIncorporates research outcomes and best practices into decision making and practiceXX
      2.7EUses advanced training, research, and emerging science in decision making and practiceX
      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)XXX
      2.8BCollaborates in setting organization standards of performance for pediatric nutrition staffXX
      2.8CDemonstrates knowledge and skills to train, mentor, and guide credentialed nutrition and dietetics practitioners and other support staffXX
      2.8DDesigns/develops/revises peer review process for organizationX
      2.9Mentors and/or precepts othersXXX
      2.9ARecognizes importance of and encourages mentorship and/or preceptorship opportunities with individuals from underrepresented/marginalized groupsXXX
      2.9BContributes to the educational and professional development of credentialed nutrition and dietetics practitioners, students/interns, and health care practitioners through formal and informal training activities; works to actively include individuals from underrepresented/marginalized groupsXXX
      2.9CDevelops or directs mentoring or practicum opportunities for RDNs to support achieving proficient-level practice or specialist certification applicable to pediatric nutrition (eg, CSP, CSPCC, RDN-AP, Certified Clinical Transplant Dietitian [CCTD], CDCES, IBCLC)XX
      2.9DSeeks opportunities to participate in mentor programs with credentialed nutrition and dietetics practitioners, health care practitioners, or other professionalsXX
      2.9EFunctions as a mentor or preceptor in pediatric nutrition for competent- and proficient-level RDNs or health care practitioners of other disciplinesX
      2.9FDesigns, operates, and evaluates mentor programs for credentialed nutrition and dietetics practitioners and other health care practitioners (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
      2.10AObtains and maintains specialist credentials(s) (eg, CSP, CSPCC, RDN-AP)XX
      2.10BServes as expert to local, state, and national accrediting agencies for competent through expert pediatric nutrition practice standardsX
      2.10CDevelops programs, tools, and resources in support of assisting RDNs in obtaining advanced practice certification relevant to pediatric nutrition practiceX
      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 programs tailored to the needs of the organization and the patient/client populationXX
      3.1A2Leads or contributes to the development or revision of the stated mission, vision, and service expectations and outputs of the organizationX
      3.1A3Designs, 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
      3.1B1Participates in program and service planningXXX
      3.1B2Seeks input from the patient/client/caregiver to improve program/service deliveryXX
      3.1B3Accommodates anticipated patient/client/caregiver needs and identified goals and objectives in pediatric nutrition program development and deliveryXX
      3.1B4Synthesizes service and program outcomes to create offerings that meet patients’/clients’ and families’/caregivers’ needsX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Adapts program and service delivery to align with budget requirements, staffing, and organization/program prioritiesXX
      3.1C2Advocates for staffing and resources that support patient/client population, census/caseload, acuity, and program services and goalsXX
      3.1DProposes programs and services that are customer-centered, culturally appropriate, and address disparities and inequitiesXXX
      3.1D1Adapts practice to address or eliminate health disparities associated with culture, race, gender, socioeconomic status, age, health literacy, and other factorsXXX
      3.1D2Develops programs and services that are tailored to patient/client population characteristics, including health status and social determinants of healthXX
      3.1D3Advocates for and leads the development of resources and pediatric nutrition services to meet needs of underserved populationsX
      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 and develops processes to receive or make referrals that address the needs of the pediatric population (eg, pediatrician, pharmacist, respiratory therapist, mental/behavioral health professional, physical therapist, speech-language pathologist)XX
      3.2A2Designs referral systems that match qualified RDNs in pediatric nutrition practice with the needs of the publicXX
      3.2A3Leads team in developing and/or revising referral tools and processesX
      3.2BRefers customers to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practiceXXX
      3.2B1Refers customers to providers who use an evidence-based approach and adhere to their professional standards of practiceXXX
      3.2B2Establishes and maintains networks to support the overall care of pediatric patients/clientsXX
      3.2B3Supports referral resources with curriculum and training related to pediatric nutritionX
      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
      3.2C2Collaborates with regional/national pediatric nutrition screening and/or referral efforts and data collectionXX
      3.2C3Evaluates pediatric nutrition screening and/or referral systems and collaborates with regional/national data analysisX
      3.2C4Leads 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 health/illness experiences and the patient/client population’s access to and use of servicesXXX
      3.3A2Conducts needs assessment considering social determinants of health in collaboration with interprofessional team and community stakeholders to identify patient/client population’s needsXX
      3.3A3Develops needs assessments to identify patient/client population’s needsX
      3.3BUses knowledge of the customer’s/target population’s health conditions, culture, beliefs, and business objectives/services to guide design and delivery of customer-centered servicesXXX
      3.3B1Adapts programs/services to meet the needs of diverse pediatric populations and their families/caregiversXXX
      3.3B2Participates in or plans, develops, and implements systems of care and services to meet the needs of diverse pediatric populations and their families/caregiversXX
      3.3B3Leads in applying, evaluating, and communicating the effectiveness of different theoretical frameworks for interventions (eg, health belief model, social cognitive theory/social learning theory, stages of change/transtheoretical model) in pediatric nutritionX
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target populationXXX
      3.3C1Identifies patient/client population’s cultural or health-related beliefs regarding health condition(s) that influence delivery of pediatric nutrition education and careXXX
      3.3C2Advises on and uses systems or tools for communicating disease prevention and behavior change principlesXX
      3.3C3Develops and implements clinical pathways/protocols that use disease prevention and behavior change principlesX
      3.3DCollaborates with customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomesXXX
      3.3D1Adapts practice to address barriers to change and/or barriers to the use of health care services to meet patients’/clients’/caregivers’ needsXXX
      3.3D2Participates in development of tools to promote shared decision making and goal settingXX
      3.3D3Establishes systems and/or develops tools to promote collaborative decision makingX
      3.3EInvolves customers in decision makingXXX
      3.3E1Includes patient/client/caregiver or other interprofessional team member input in decision-making processXXX
      3.3E2Facilitates patients’/clients'/caregivers’ participation in health care decision making and goal settingXX
      3.3E3Develops systematic approaches and policies that facilitate customer participationX
      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
      3.4A1Interacts with interprofessional team to:
      • educate and develop skills
      • demonstrate role of RDN and nutrition in care of patient/client population
      • contribute formally and informally to the patient/client care team (eg, share relevant articles and investigate queries)
      • communicate nutrition strategies guided by evidence-based guidelines/best practices
      XXX
      3.4A2Collaborates with interprofessional team and other health care practitioners to:
      • plan and deliver appropriate products and services (eg, medical foods/nutrition supplements, referrals to specialists, use of community resources)
      • provide education or community programs
      XXX
      3.4A3Serves as a consultant for issues related to pediatric nutritionXX
      3.4A4Facilitates interprofessional discussions and care planning for pediatric patients/clientsXX
      3.4A5Leads interprofessional and/or interagency teamsX
      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
      3.4B1Implements and manages customer services and programs (eg, community-based nutrition education programs) using evidence-based strategies and available resourcesXX
      3.4B2Plans, develops, and evaluates customer programs and services, using evidence-based strategies and available resourcesX
      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 pediatric nutrition–related servicesXXX
      3.4C2Develops or maintains pediatric nutrition protocols, policies, and procedures based on research, national and international evidence-based guidelines, and best practicesXX
      3.4C3Collaborates with the interprofessional team and orients staff on new or revised policies/procedures/protocols; monitors success/follow-through, and amends as neededXX
      3.4C4Incorporates RDN and nutrition and dietetics technician, registered scope of practice into organization policies and procedures and standards of careXX
      3.4C5Modifies organization policies and/or standards of care to reflect current scope of practice and applicable laws and regulationsX
      3.4C6Supervises or leads the development of organization- clinical protocols guiding delivery of careX
      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 non-physician practitioners who are determined to be eligible for appointment by the governing body.6
      or medical director, 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.6,7 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.9,10
      –driven delegated orders or protocols (eg, initiating or modifying orders for therapeutic diets, medical foods/nutrition supplements, dietary supplements, enteral and parenteral nutrition, 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; enteral or parenteral nutrition; supplemental water); seeks assistance if neededXXX
      3.4D1iiContributes to organization/medical staff process for identifying RDN privileges or delegated orders to support nutrition care and services (eg, ordering or revising diet, medical food/nutrition supplements, enteral or parenteral nutrition, vitamin/mineral supplements, or other nutrition-related orders)XX
      3.4D1iiiWorks to incorporate RDN privileges into organization policies, procedures, and/or protocolsXX
      3.4D1ivAdvocates, negotiates, or establishes nutrition privileges at a systems levelX
      3.4D2Uses and participates in or leads development of processes for privileging for provision of nutrition-related services, including (but not limited to) lactation support, inserting nasoenteric feeding tubes, case management services (eg, home enteral nutrition or infusion management), and indirect calorimetry measurementsXXX
      3.4D2iParticipates in or leads the development of processes for privileging for provision of nutrition and related servicesXX
      3.4D2iiCollaborates in the development of RDN privileges and/or physician-driven protocols for:
      • inserting and managing nasoenteric feeding tubes
      • managing patients/clients using continuous glucose monitors and/or CSII
        CSII = continuous sustained insulin infusion (ie, insulin pump).
        (ie, insulin pump) devices
      • 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
      3.4E1Develops tools to monitor adherence to organization policies, billing regulations, and ethical billing practicesXX
      3.4FCommunicates with the interprofessional team and referring party consistent with HIPAA rules for use and disclosure of customer’s protected health information (PHI)XXX
      3.4F1Develops processes and tools to monitor adherence to HIPAA rules or address breaches in protection of PHI and use of electronic medical records (on site or through remote access)XX
      3.5Assigns 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
      3.5A1Develops and modifies department and/or organization policies related to role of support personnelXX
      3.5A2Determines capabilities/expertise of professional, technical, and support staff working with patients/clients/families 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 cultural and related needs and preferences of target populations (eg, health care patients/clients, employee groups, visitors to retail venues, schools, childcare centers, community feeding sites, farm to institution initiatives, local food banks)XXX
      3.6A1Collects data and provides feedback on food delivery systems serving infants, children, and adolescents in health care and community settings (eg, hospital, outpatient ambulatory care facilities, school or childcare sites, food banks/pantries, home delivery)XXX
      3.6A2Participates in or designs, evaluates, and/or revises food/formula delivery systems for specific pediatric populations, settings, and emergency events (eg, natural disasters, pandemics, supply-chain interruptions)XX
      3.6A3Consults on design, evaluation, or modification of food delivery systems in health care and community settings (eg, meal programs, food banks/pantries serving food insecure) to identity and support the needs of the pediatric populationX
      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 protocols for advancing or transitioning to oral feedings for patients/clients who receive enteral or parenteral nutritionXX
      3.6B2Reviews and/or approves menu and snack options reflecting national nutrition recommendations (eg, Pediatric Nutrition Care Manual, Dietary Guidelines for Americans, Academy EAL), applicable regulations, and cultural preferences; modifies or approves offerings within therapeutic diet guidelinesXX
      3.6B3Develops menu and snack guidelines that reflect national recommendations and applicable federal or state regulations to guide foodservice program(s)X
      3.6CParticipates in, consults/collaborates with, or leads interprofessional process for determining medical foods/nutritional supplements, dietary supplements, enteral and parenteral nutrition formularies, and delivery systems for target population(s)XXX
      3.6C1Actively participates in the process for determining human milk, infant formulas, medical food/nutrition supplements, enteral and/or parenteral nutrition formulas and delivery systemsXXX
      3.6C2Provides guidance regarding human milk, infant formulas, medical foods/nutritional supplements, enteral or parenteral nutrition formulas in accordance with best practices in pediatrics (eg, AAP, Academy, ASPEN)XX
      3.6C3Collaborates in or leads:
      • interprofessional process for determining enteral and/or parenteral nutrition 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 pediatric nutritionXX
      3.7A3Leads development of tools for measuring and reporting dataX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7B1Develops or collaborates with the interprofessional team to capture pediatric nutrition-specific data through electronic health records or other data collection toolsXX
      3.7B2Seeks opportunities to contribute expertise to national bioinformatics/medical informatics projects as applicable/requiredX
      3.7CUses data to document outcomes of services (eg, staff productivity, cost/benefit, budget compliance, outcomes, quality of services) and provide justification for maintenance or expansion of servicesXXX
      3.7C1Organizes records for retrospective data analysis for evaluation of servicesXX
      3.7C2Analyzes and uses data to communicate value of pediatric nutrition services in relation to patient/client population and organization outcomes/goalsXX
      3.7C3Leads data analysis for evaluation of pediatric nutrition servicesX
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Prepares and presents nutrition care service and 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 with federal and state legislators regarding needs of pediatric population and benefit of nutrition services (eg, responds to Academy Action Alerts and other calls to action)XXX
      3.8A3Interacts with and serves as a resource to legislators, payors, and policy makers to contribute to and influence pediatric care and services (eg, providing testimony at legislative and regulatory hearings and meetings)XX
      3.8A4Serves as an expert resource to law and policy makers and contributes to development/review of comments and recommendations on policy, statutes, administrative rules, and regulationsX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Participates in activities that promote the provision of and access to food and pediatric nutrition care and related services, including networking with others with similar interests, at the department or organization levelXXX
      3.8B2Identifies needs and opportunities for pediatric population advocacy and participates in efforts to address issue(s)XX
      3.8B3Participates in activities that influence pediatric nutrition policy and services and seeks opportunity for collaboration, for example:
      • advocates for change in reimbursement for pediatric nutrition therapy and/or related supplies
      • provides data to support pediatric nutrition services
      • authors articles or delivers presentations that support pediatric nutrition services
      • leads interprofessional and/or interagency committees that are related to service provision
      XX
      3.8B4Leads and develops public policy related to food and pediatric nutrition services at a regional or national levelX
      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 advocacy activities for protection of the publicXX
      3.8C2Participates in regional or national activities related to pediatric nutrition policy and services; seeks opportunities for collaborationXX
      3.8C3Leads local, regional, or national advocacy effortsX
      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)
      • Patient-/client-/caregiver-centered needs and preferences are met
      • Customers are satisfied with services and products
      • Customers have access to food assistance
      • Customers have access to appropriate food and nutrition services
      • Menus reflect the cultural, health, and/or nutritional needs of target population(s) and consideration of ecological sustainability
      • Evaluations reflect expected outcomes and established goals
      • Effective screening and referral services are established or implemented as designed
      • Professional, technical, and support personnel are supervised 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 of, participation in, and generation of research to promote improved safety and quality 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
      4.1BEvaluates strength of original research and evidence-based guidelines, including limitations, potential bias, reliability, and potential practice applicationsXXX
      4.1CIdentifies key questions and uses systematic methods to obtain published evidence to answer questions and inform decisionsXX
      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, and effective quality care for patients/clients receiving pediatric nutrition care or servicesXXX
      4.2BApplies 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
      4.2CCritically evaluates the available scientific literature in situations where evidence-based practice guidelines for nutrition in pediatrics are not establishedXX
      4.2DMentors others in applying evidence-based research and guidelines to practiceXX
      4.2EDevelops and disseminates evidence-based practice guidelinesX
      4.3Integrates best available research/evidence and information with best practices, clinical and managerial expertise, and customer valuesXXX
      4.3AIntegrates research, best practices, expertise, and customer characteristics and values to define organization policies and proceduresXX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AParticipates in efforts to link research and practice (eg, journal clubs, interprofessional discussions)XXX
      4.4BCollects data to contribute to pediatric nutrition research (eg, within organization or through registries such as NICHD Neonatal Research Network, CF Patient Registry, VON) and participates in research activities (eg, data analysis, research design, publication)XXX
      4.4CParticipates in practice-based research networks (eg, Academy Nutrition Research Network, EAL workgroup, Academy ASPEN Indicators of Malnutrition Validation and Optimal Staffing Study)XX
      4.4DParticipates in the development, evaluation, selection, and revision of goals and indicators (eg, Pediatric Malnutrition Consensus Statement indicators)XX
      4.4EIdentifies and initiates research relevant to pediatric nutrition practice as the primary investigator, or as a collaborator with other members of the health care team or communityX
      4.4FServes as an advisor, preceptor, and/or committee member for graduate-level researchX
      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 research that will contribute to the evidence base for pediatric nutritionXXX
      4.5BCollaborates with interprofessional and/or interorganizational teams to develop, perform, and/or disseminate pediatric nutrition and related researchXX
      4.5CAdvocates to stakeholder organizations, groups, and/or agencies for prioritizing and funding of pediatric nutrition research projectsXX
      4.5DLeads interprofessional and/or interorganization research efforts related to pediatric nutritionX
      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 are 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
      5.1BConveys more than procedural understanding by communicating significant informationXX
      5.1CDemonstrates flexibility, critical thinking, and innovation with the ability to effectively apply and communicate complex ideasX
      5.2Selects appropriate information and the most effective communication method or format that considers patient-/client-/caregiver-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
      5.2A1Uses the communication method(s) best suited to effectively convey the intended message to the target audience(s)XXX
      5.2BUses appropriate information technology to communicate, disseminate, manage knowledge, and support decision makingXXX
      5.2B1Consults in development and/or application of information technology to communicate, disseminate information, and support decision making related to pediatric nutrition (eg, leads professional networking groups, develops social media applications)XX
      5.2B2Directs the development and/or application of information technology to communicate, manage knowledge, and drive decision making related to pediatric nutritionX
      5.3Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3AIntegrates research and professional judgment in a variety of specialized practice areas (eg, genetics, oncology, CF, and transplant)XX
      5.3BUses innovative approaches in varied contexts with patients/clients/families/caregivers, colleagues, and the public (eg, using social media to provide anticipatory guidance to families/caregivers about starting solid foods; Project ECHO—delivering specialized training to a network of health care professionals)X
      5.4Shares current, evidence-based knowledge, and information with various audiencesXXX
      5.4APresents evidence-based pediatric nutrition information at the local level (eg, community groups, colleagues, health care administrators, and executives)XXX
      5.4BPresents evidence-based pediatric nutrition information at the regional and/or national levelXX
      5.4CAuthors pediatric nutrition and related publications; presents topics related to pediatric nutrition to consumers and health care practitionersXX
      5.4DGuides customers, families, students, and interns in the application of knowledge and skillsXXX
      5.4D1Develops and updates educational programs that promote and elevate safe and effective pediatric nutrition practiceXX
      5.4D2Fulfills formal teaching or faculty role as an expert in pediatric nutritionX
      5.4D3Designs training curriculum (eg, experiential, didactic, simulation, and case-based learning and peer-to-peer evaluation) to advance skills in pediatric nutritionX
      5.4EAssists individuals and groups with identifying and securing appropriate and available educational and other resources and servicesXXX
      5.4E1Refers individuals and groups to appropriate programs and servicesXXX
      5.4E2Recommends current, evidence-based pediatric nutrition education resourcesXXX
      5.4E3Contributes to the development and compilation of educational materials and other resources that meet the needs of, and are tailored to, the target populationXX
      5.4E4Works cooperatively with others to develop new ideas, coordinate resources, and produce innovative resources or approachesXX
      5.4E5Leads the development and revision of person- and family-centered, evidence- and outcomes-based resources and services necessary to meet nutrition and health needsX
      5.4E6Evaluates use and impact of resources and materials; collaborates to improve content and/or dissemination as appropriateX
      5.4FUses professional writing and verbal skills in all types of communicationsXXX
      5.4F1Uses appropriate professional approach to oral and written communicationsXXX
      5.4GReflects knowledge of population characteristics in communication methods (eg, language; literacy and numeracy; health literacy; physical ability; intellectual, communication, hearing, or vision challenges; and cultural considerations)XXX
      5.4G1Adapts communication methods when a problem is identifiedXXX
      5.4G2Anticipates need for modification of communication methods and addresses issues ahead of timeXX
      5.4G3Works at a systems level to be sure that communications effectively reach the intended audienceX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management team, organization, and communityXXX
      5.5ACommunicates effectively with team members and patients/clients and their families/caregiversXXX
      5.5BCultivates networking relationships that foster individual and organization goalsXX
      5.5COffers effective interpretation of principles of pediatric nutrition to health care practitioners, patients/clients/families/caregivers; acts as a resource by interpreting and synthesizing information related to pediatric nutritionXX
      5.5DServes as an expert/source of information about pediatric nutrition and related topics and is recruited by colleagues, the medical community, and othersX
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6APresents performance improvement and research results at the local level (eg, community groups, colleagues, health care administrators, and executives)XXX
      5.6BPresents performance improvement and research results at the regional and/or national levelXX
      5.6CServes on organization/department/program/agency planning committees/task forces to communicate pediatric nutrition outcomes and use them in the development of plans, policies, and proceduresXX
      5.6DPublishes performance improvement and research resultsXX
      5.6EServes in leadership role for publications (eg, editor, editorial advisory board)X
      5.6FServes as a pediatric nutrition consultant (eg, to business, industry, and national organizations) in the development of practice guidelines, peer-reviewed articles, and organization position papersX
      5.6GInitiates and facilitates publications to change practice for important or emerging issues for pediatric nutritionX
      5.6HDirects collation of research data into publications (eg, systematic reviews and position/practice papers), as well as national/international presentationsX
      5.7Participates in and assumes leadership roles with local, state, and national professional and community-based organizations (eg, government-appointed advisory boards, community coalitions, schools, foundations, or nonprofit organizations) providing food and nutrition expertiseXXX
      5.7AServes on regional and national pediatrics-related practice committees/task forces for health practitioners or industryXX
      5.7BPursues leadership development opportunities in local, regional, and national pediatric nutrition–related organizations, coalitions, or advisory boardsXX
      5.7CPresents pediatric nutrition information to establish collaborative practice at a systems levelX
      5.7DWorks to be selected for leadership positions and is identified as expert related to pediatric nutrition issuesX
      5.7EIdentifies opportunities for leadership and interprofessional collaborationX
      5.7FActs as resource to inform development of laws and regulations related to pediatric nutrition practice (eg, provides information to state licensure board)X
      Examples of Outcomes for Standard 5: Communication and Application of Knowledge
      • Expertise in food, nutrition, dietetics, and management is demonstrated and shared
      • Information technology is used to support practice
      • Effective and efficient communications occur through appropriate and professional communication strategies (eg, print, oral, electronic, social media)
      • Individuals, groups, and stakeholders:
        • Receive current and appropriate information and customer-centered service
        • Demonstrate understanding of information 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
      6.1ARecognizes and uses existing resources appropriately (eg, staff time, educational/training tools and materials)XXX
      6.1BParticipates in operational planning and management of pediatric nutrition programs and services (eg, staffing, human milk/formula room, marketing, budgeting, information management system/tools, emergency planning, billing)XX
      6.1CIntegrates collaboration and partnerships with local and regional programs (eg, Cooperative Extension, university programs, public health departments, training facilities) into strategic and operational planningXX
      6.1DCollaborates on adjustments to staffing and/or workflow patterns to optimize outcomes through efficient use of resourcesX
      6.1EDirects or manages the design and delivery of pediatric nutrition servicesX
      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
      6.2BParticipates in collecting and analyzing outcomes data, program resource/service participation, and operational data (eg, expenses, staff hours, hours of operation) to evaluate and adjust programs and servicesXXX
      6.2CLeads and participates in data collection regarding the population served, services provided, and outcomes (eg, demographics, staffing benchmarks, program participation rates, reimbursement/payment data)XX
      6.2DLeads operational review of performance and benchmarking data to manage resources and modifications to the design and delivery of pediatric nutrition programs and servicesX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and productsXXX
      6.3AParticipates in evaluation, selection, and/or implementation of new products, equipment, and services to ensure safe, optimal, and cost-effective delivery of pediatric nutrition care and servicesXXX
      6.3BEvaluates and articulates care and service needs when justifying the products and services necessary to meet the population’s desired nutrition outcomesXX
      6.3CEvaluates safety, effectiveness, and value of programs and services in meeting the needs of the target population(s); recommends or adjusts procedures to support or improve outcomesX
      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) and recommending modificationsXXX
      6.4BUses data to evaluate and modify resource management or delivery of services (eg, staffing, triage, education materials/tools)XX
      6.4CLeads interprofessional team in QAPI or in applying best practices to manage resourcesXX
      6.4DIntegrates quality measures and performance improvement processes into management of human and financial resources and information technologyX
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators)XXX
      6.5AParticipates in developing or conducting surveys of patients/clients/families, team members, and other stakeholders to assess satisfactionXXX
      6.5BAnalyzes data related to program services and stakeholder satisfaction; communicates results and recommendations for changesXX
      6.5CImplements, monitors, and evaluates changes based on data collection and analysisX
      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 and tracked in alignment with organizational mission, vision, principles, and values
      a EAL = Academy Evidence Analysis Library (www.andeal.org/).
      b ASPEN = American Society for Parenteral and Enteral Nutrition (www.nutritioncare.org).
      c 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; nutrition and dietetics technicians; physician assistants; nurse practitioners; pharmacists; psychologists; social workers; lactation consultants; occupational and physical therapists; speech language pathologists; behavior analysts/therapists; educators; and family resource coordinators), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      d 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.
      e 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 non-physician 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.
      f 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.
      g CSII = continuous sustained insulin infusion (ie, insulin pump).
      h DEXA = dual energy x-ray absorptiometry.
      i CT = computed tomography.

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      Biography

      B. Ogata is a lecturer, Department of Pediatrics, University of Washington, Seattle.
      L. Nieman Carney is a clinical dietitian IV and inpatient staff relief and publication specialist, The Children’s Hospital of Philadelphia, Philadelphia, PA.