Purpose:
 
To define the specific roles, functions, responsibilities and activities of Clinical Dietitian in different clinical areas.

Definitions:

1. Dietetics: it is the integration and application of principles derived form the science of food, nutrition and management, communication, biological, physiological, behavioral and social service to achieve and maintain optimal human health.
2. American Dietetic Association (ADA): is the national professional association, which accredits educational and pre-professional training programs in dietetics. ADA considered being a reference of scientific guidelines and protocols for our Clinical Nutrition Department.
3. Scope of Practice:  defines the activities, and responsibilities of a Registered Clinical Dietitians who are skilled in performing activities outlined in their respective Scope of Practice and are evaluated through local competency assessment tools and a professional oversight process.
4. Nutrition Care Process (NCP): is a systematic problem solving method that dietetic professionals use to critically think and make decisions to address nutrition related problems and provide safe and effective quality nutrition care.
5. Nutrition Assessment: is the systematic process of obtaining, verifying and interpreting data (laboratory results, anthropometric, physical, and dietary) in order to make decisions about the nature and cause of nutrition-related problems.
6. Nutrition Diagnosis: involves the identification and labeling that describes an actual occurrence of, a risk of or potential for developing nutritional problems that qualified dietetic professionals are able to treat independently. A nutrition diagnosis provides a link to setting realistic and measurable goals, identifying expected outcomes, selecting appropriate interventions and tracking progress towards attaining those expected outcomes.
7. Nutrition Interventions: are purposefully planned actions to change a nutrition related behavior or risk factor. It involves selecting, planning and implementing appropriate actions to meet the patient’s nutrition needs and is driven by the nutrition diagnosis and provides the basis upon which outcomes are measured and evaluated.
8. Nutrition Monitoring and Evaluation: Monitoring refers to the review and measurement of a patient’s status at pre-planned follow-up points with regard to the nutrition diagnosis, intervention goals and outcomes. Evaluation is the systematic comparison of current findings with previous status intervention goals or a reference standard. The purpose of monitoring and evaluation is to determine the degree to which progress is being made and goals or desired outcomes of nutrition care are being met.
9. Nutrition Screening: is an interdisciplinary process which involves gathering pre-established data from the medical record, computer, or by brief patient interview. The collected data is then evaluated to determine if the patient is nutritionally compromised or at risk for malnutrition, based on the criteria developed by the dietitian and the interdisciplinary care team.
10. Nutrition Education: The nutrition education process utilizes instruction or counseling to bring about desirable changes in behavior, attitudes, environmental influences, and understanding of food. Such desirable changes lead to food and nutrition practices which are scientifically sound, practicable, and consistent while meeting individual needs with available food resources.

Policy Statements:

Clinical Dietitians do provide a Clinical Nutrition Services through Nutrition Care Process (NCP) as described by American Dietetic Association (ADA). The NCP includes Nutritional Assessment, Nutrition Diagnosis, Nutrition Intervention, Monitoring and Evaluation.

Procedures:

• Chief Clinical Nutrition Services delegates the responsibility for administering the Clinical Nutrition program and supervising the Clinical Dietitian and Dietetic Technician whom are the primary providers of medical nutrition therapy for eligible  patients.

• The Clinical Dietitian is responsible for:
•  Providing for the patient’s overall nutritional care by using:
• Pertinent data obtained from the patient or caregiver
• The medical record and directly from health care team members
• Preparing and implementing each interdisciplinary medical nutrition therapy care  plan.
• Evaluating the patient’s nutrition therapy and status in terms of process and  outcome.
• Direct Patient Service:
• The Clinical Dietitian functions as a consultant on the healthcare team in different   clinical areas such as:
• General medical
• Surgical patients
• Pediatric patients
• Gestational diabetes and other risk pregnancies
• TPN requiring patients
• ICU patients
• Renal patients on Hemodialysis/Peritoneal dialysis as well as renal transplant progra
• Patients on long term care units
• Coronary care units
• Nutrition Counseling is provided both in In-patient and Out-patient in Nutrition  Clinics and Specialty clinics.
• Participates Discharge planning meeting for patient care.
•  Indirect Patient Service:
• In conjunction with Food Service Staff, coordinates planning and direct orders for  patient meals and enteral formulas.
• Provides training programs to Dietetic Internship, SCDP, Summer Training,  Doctors, Nurses, and Food Service Staff
• Participates in inside & outside hospital activities annually e.g. World Diabetes  Day.
• Conducts continuing professional education presentations to co- dietitians.
• Produces educational materials regarding healthy eating guidelines and  therapeutic diets both for hospital staff and patients.
• Scope of Practice: 
• Medical Nutrition Services are provided to all eligible patients in all treatment  modalities:  
• Acute.
• Extended care or Long-term care.
• Ambulatory care and community care programs.
•  Clinical Dietitians provide medical nutrition services outlined in the following  Scope of Practice:
• Nutrition Assessment:
• Nutrition History:
• Evaluation of nutrient intake and hydration status;
• Activity level;
• Appetite;
• Intake of vitamins, minerals, and/or nutrition supplements;
• Recent weight change;
• Weight history;
• Taste change(s);
• Eating and feeding problems;
• Nausea;
• Vomiting;
• Diarrhea;
• Constipation;
• Food intolerances, adverse reactions and/or allergies;
• Food-drug interactions;  
• Unhealthy dietary behaviors;
• Eating disorders;
• Socioeconomic, religious, ethnic and cultural background;
• Herbal and/or complementary nutrition therapies; and
• Lifestyle practices to include complementary and alternative therapies.
• Documented Medical History
• Current Diagnosis and Medical Treatment Modalities
• Current Drug Therapy and Over the Counter Medication
• Anthropometric Measurements:
• Height
• Weight
• Clinical Signs and Symptoms of Nutritional Deficiencies
• Medical Nutrition Therapy Plan and Intervention:
•  In cooperation with patients or significant others and with other medical    center disciplines, the dietitian develops and implements the interdisciplinary    nutrition care plan and communicates, monitors, and documents (in the     medical record) response to nutrition therapy in accordance with Joint     Commission on Accreditation of Healthcare  Organizations ( JCAHO).
• The plan and intervention includes:
• Calorie and nutrient requirements (using indirect calorimetry, basal energy expenditure (BEE) and resting energy expenditure (REE) formulas).
• Current diet prescription or nutrition support recommending appropriate changes.
• Initiating or making alterations in diet prescriptions or nutritional therapies per locally established guidelines.
• Ordering adjustments in the calorie level of the diet based on patient’s calorie and nutrient requirements
• Ordering consistency modifications for the diet based on patient’s tolerance and clinical status
• Ordering changes in feeding schedules and adjusting the quantity of food according to patient’s tolerance
• Prescribing nutrition supplements, as appropriate, within diet order or medical nutrition therapy plan
• Determining appropriate feeding modalities for oral diets, i.e., recognizing the need and recommending specialized nutrition intervention (enteral or parenteral nutrition). 
• Identifying nutrition inadequacies due to prescribed dietary restrictions and  individualized patient needs. 
• Establishing nutritional therapy and educational goals.
• Planning and implementing appropriate modifications and interventions.
• Initiating follow-up at defined intervals to ensure established nutrition  intervention and educational goals and outcomes are met.
• Monitoring Response to Nutrition Therapy: 
• Continually identifying the need to alter the care plan by evaluating    modalities, intervention methods, and the patient’s response to the intervention used.
• Ordering appropriate laboratory tests to monitor nutritional status in    accordance with locally established policy.
• Ordering measured weights and heights as appropriate.
• Nutrition Counseling:
• The dietitian initiates nutrition counseling consistent with the patient’s current diet or nutrition therapy needs, recording intervention, and counseling in the medical record. This includes the patient’s degree of comprehension and the clinician’s assessment of the patient’s readiness to learn, expected compliance, and identification of respective barriers.
• Providing nutrition counseling to patients when food-drug interaction significantly alters the patient’s food selection.
• Evaluating and documenting progress toward desired outcomes and/or goals.
• Initiating health maintenance nutrition education.
• Evaluating and implementing alternate method(s) or system(s) for nutrition education, as appropriate.
• Monitoring, evaluating, and documenting individualized nutrition therapy plans.
• Referring or scheduling patients for follow-up in the Ambulatory Care Nutrition Clinic or inpatient and/or outpatient group education activities.
• Evaluating educational materials for content, reading level, and other pertinent factors.
• Employing computer application in nutrition intervention, when appropriate.
• Documenting findings utilizing established practice guidelines and quality improvement and assessment indicators.
• Nutrition Therapy Process:
• The dietitian participates with other health care team members and the patient in planning and implementing suitable therapy intervention(s) through the exchange of information and education.
• Actively participating in interdisciplinary team meetings, ward rounds, discharge planning conferences, peer reviews, performance improvement activities, etc., to monitor and share findings and recommendations with team members.
• Educating the interdisciplinary team members on the role of nutrition in health and disease and the role of the clinical dietitian in giving nutrition guidance.
• Serving as a consultant to the medical and supporting staff regarding diet prescriptions and modifications, nutrition assessment, current nutrition concepts, and research related to nutrition.
• Providing consultation and training to other appropriate health care programs and services.
• Initiating or participating in nutrition research.
   
• Overseeing the work of the clinical dietetic technician and health technician (dietetic) and remaining responsible for decisions and judgments concerning the patient’s overall nutrition therapy process.
• Expanded Scope of Practice:
• Dietitian applicants for Expanded Scope of Practice must be approved for General  Scope of Practice.
• The request for Expanded Scope of Practice is considered in those  instances  where specialized skills are required, or when the activity falls outside of the  established scope, as determined by the Chief Clinical Nutrition Services.
• The applicants  must have documented recent training or certification in the area  of specialized practice for which Expanded Scope of Practice is sought, and must  have  demonstrated competence to perform the functions of the requested specialized  patient  care service.
• Examples of expanded scope of practice for registered dietitians may include, but  are not limited to:
• Home Glucose Monitoring.
• Addictive Behavior Counseling.
• Enteral Tube Placement.
• Nutrition Screening:
• New admissions are screened by nurses to determine whether they are  nutritionally compromised, or at nutrition risk.
• A nutrition status or nutrition risk level is assigned for each patient after  evaluation and/or assessment is completed.
• Clinical nutrition staff use assigned nutrition status or risk levels to prioritize  nutritional interventions.
• Facility Diet Manual:
• The facility diet manual serves as a reference for ordering  diets, standards for  nutrition therapy, and serves as a reference in menu and/or recipe preparation. The  standards for nutrition therapy and analysis specified in the facility diet manual are in  accordance with the most recent Recommended Dietary Allowances (RDA) of the  Food and Nutrition Board, National Research Council, National Academy of  Sciences. The nutritional deficiencies of any diet that is not in compliance with the  recommended dietary allowances are specified.
• A facility diet manual must be developed or adopted by the dietitian in  cooperation with appropriate staff. The diet manual must be updated and revised per  regulatory guidelines. Revisions are approved by the appropriate medical staff, and  dated to identify the review date.
• The facility diet manual must be available in all patient care  areas.
• Diet Prescription:
• The physician, Clinical Dietitian and nurse writes the diet prescription (order) in  the medical record or electronically, using terminology and diets approved in the  medical nutrition manual.
   
• Supplemental feedings are prescribed by the physician, Clinical Dietitian and  nurse, in consultation with the dietitian, according to policy established at King Abdu- Aziz Medical City-Jeddah (KAMC-J).
• Dietitians order changes to diet orders written as defined in local Scope of  Practice.
• There is an established procedure in place to verify that the recorded diet order is  served to the patient. There is also a system to identify the patient prior to receiving the  food.
• The diet prescription provides for the patient's nutritional requirements within  medical limitations, based on the patient's assessed nutritional needs.
• Menus:
• A procedure is established to verify that all-master regular menus and modified  diets are approved by a registered dietitian. Menus are analyzed for nutrient content  and adequacy and posted for review in patient treatment areas where applicable.
   
• Cyclic menus are planned by the Chief Food Services to meet the nutrition needs  of the population mix incorporating regional preferences consistent with diets approved  in the diet manual.
• Nutrition Education:
• Nutrition education, an essential component of medical nutrition therapy and  services, helps individuals establish and maintain healthy lifestyles, good food habits  and attitudes. Education encompasses the following groups:
• Patients:
• Individual and group instructions on the prescribed medical     nutrition therapy are planned and scheduled as soon as medically feasible.
• Local policy is developed to prioritize nutrition education for     patient and family based on whether the medical nutrition therapy plan is     new to the patient, will be a "refresher" of previous therapy instruction,     and the patient and family’s ability to comprehend and apply the therapy     plan.
• Patient education material and handouts are consistent with the facility diet manual.
• Health maintenance and preventive nutrition therapy are an integral part of the Nutrition Education Program.
• All patient education will be documented in the medical record.
• Family Members or Significant Others
• Staff
• Community Caregivers.
• Students-in-Training Programs.
• Interdisciplinary Care Team Planning:
• The clinical dietitian is active members of the interdisciplinary care planning  team so that medical nutrition therapy is integrated into the patient’s care plans as  needed.
• The dietitian prepares medical nutrition therapy goals for the patient’s care plan  and discharge plan as needed, to facilitate continuity of care in the ambulatory care  unit, acute care, extended care, long-term care, and in the community.
• Support of Patient Care Programs:
• Programs and services with a nutrition component are supported by clinical  dietitian(s). These include, but are not limited to:
• Ambulatory Care Clinics.
• Home Health Care (HHC).
• Long Term Patients.
• Primary Health Care Centers.
• Bone Marrow Transplant Units.
• Rehabilitation Programs.
• Spinal Cord Injury (SCI) Service.
• Dialysis Unit.
• Solid Tissue Transplant Programs.
• Diabetes Education Programs.

• American Dietetic Association, Scope of Dietetics Framework, JADA 2005 (105)4 (634-640).
• American Dietetic Association: Commission on Dietetic Registration. 1996-1999, WEB Site - http://www.eatright.org/crd.html.
• American Dietetic Association Standards of Professional Practice for Dietetic Professionals, Journal of American Dietetic Association, Volume 98 (1), 1998.
• Code of Ethic for the Profession of Dietetics: Journal of the American Dietetic Association, January 1999.
• “The Role of Nutrition in Health Promotion and Disease Prevention Programs,” Position Paper of the ADA, Journal of the American Dietetic Association, Volume 98 (2),  1998.