ADA Parenteral Enteral

FROM THE ACADEMY
Standards of Practice and Professional Performance
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
Mandy L. Corrigan, MPH, RD, CNSC, FAND, FASPEN; Elizabeth Bobo, MS, RD, LDN, CNSC;
Christina Rollins, MBA, MS, RDN, LDN, CNSC, FAND; Kris M. Mogensen, MS, RD-AP, LDN, CNSC
ABSTRACT
Nutrition support is a therapy that crosses all ages, diseases, and conditions as health care practitioners strive to meet the nutritional
requirements of individuals who are unable to meet nutritional and/or hydration needs with oral intake alone. Registered dietitian
nutritionists (RDNs), as integral members of the nutrition support team provide needed information, such as identification of malnu-
trition risk, macro- and micronutrient requirements, and type of nutrition support therapy (eg, enteral or parenteral), including the
route (eg, nasogastric vs nasojejunal or tunneled catheter vs port). The Dietitians in Nutrition Support Dietetic Practice Group, American
Society for Parenteral and Enteral Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have
updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nutrition support. The
SOP and SOPP for RDNs in Nutrition Support provide indicators that describe the following 3 levels of practice: competent, proficient,
and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes
the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP depict how these standards
apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for
assuring competent practice in nutrition support and for determining potential education and training needs for advancement to a
higher practice level in a variety of settings.
J Acad Nutr Diet. 2021;121(10):2071-2086.
Editor’s note: Figures 1 and 2 that Academy Quality Management Com- Registration’s (CDR) Code of Ethics for
accompany this article are avail- mittee and ASPEN Clinical Practice the Nutrition and Dietetics Profession4
able online at www.jandonling.org. Committee, have revised the Standards along with the Academy of Nutrition
of Practice (SOP) and Standards of and Dietetics: Revised 2017 SOP in
T
HE DIETITIANS IN NUTRITION
Professional Performance (SOPP) for Nutrition Care and SOPP for RDNs3
Support Dietetic Practice Group
Registered Dietitian Nutritionists
(DNS DPG) of the Academy of
(RDNs) in Nutrition Support previously Approved May 2021 by the Quality Man-
Nutrition and Dietetics (Acad-
published in 2014.1,2 The revised docu- agement Committee of the Academy of
emy), and members of the Dietetics Nutrition and Dietetics (Academy), the Ex-
ment, Academy of Nutrition and Die-
Practice Section of the American Soci- ecutive Committee of the Dietitians in
tetics and American Society for
ety for Parenteral and Enteral Nutrition Nutrition Support Dietetic Practice Group of
Enteral and Parenteral Nutrition: the Academy, and the Clinical Practice
(ASPEN), under the guidance of the
Revised 2021 Standards of Practice Committee and the Board of Directors of the
and Standards of Professional Perfor- American Society for Parenteral and Enteral
This article is being published concur-
rently in the Journal of the Academy of mance for Registered Dietitian Nutri- Nutrition (ASPEN). Scheduled review date:
Nutrition and Dietetics and Nutrition tionists (Competent, Proficient, and May 2027. Questions regarding the Stan-
in Clinical Practice. The articles are Expert) in Nutrition Support, reflects dards of Practice and Standards of Pro-
identical except for minor stylistic and fessional Performance for Registered
advances in nutrition support practice Dietitian Nutritionists in Nutrition Support
spelling differences in keeping with during the past 7 years and replace
each journal’s style. Either citation can may be addressed to Academy Quality
the 2014 Standards. This document Management Staff: Dana Buelsing, MS,
be used when citing this article.
builds on the Academy of Nutrition manager, Quality Standards Operations;
2212-2672/ª 2021 the Academy of Nutri- and Dietetics: Revised 2017 SOP in and Carol J. Gilmore, MS, RDN, LD, FADA,
tion and Dietetics and American Society for Nutrition Care and SOPP for RDNs.3 FAND, scope/standards of practice
Parenteral and Enteral Nutrition. specialist, Quality Management at
https://doi.org/10.1016/j.jand.2021.05.026 The Academy of Nutrition and quality@eatright.org.
Dietetics/Commission on Dietetic
ª 2021 the Academy of Nutrition and Dietetics and American Society for
Parenteral and Enteral Nutrition. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2071
FROM THE ACADEMY
and Revised 2017 Scope of Practice for based on training and certifications, if the hospital’s medical staff rules, reg-
the RDN,5 guide the practice and per- required; or additional credentials (eg, ulations, and bylaws, or other facility-
formance of RDNs in all settings. focus area CDR specialist certification, specific process.9 The actual privileges
ASPEN documents that guide the prac- if applicable, such as the Board Certi- granted may vary due to state law and
tice and performance of RDNs in nutri- fied Specialist in Pediatric Critical Care the organization and medical staff
tion support practice include the Nutrition [CSPCC], and/or Advanced along with the RDN’s knowledge, skills,
ASPEN Board of Directors-approved Practitioner Certification in Clinical experience, and specialist certification,
clinical guidelines, standards, clinical Nutrition [RDN-AP]; Certified Nutrition if required, and demonstrated and
recommendations, and position papers, Support Clinician [CNSC], Certified Case documented competence.
accessible at www.nutritioncare.org. Manager [CCM], Certified Clinical The “Long-Term Care Final Rule”
Scope of practice in nutrition and Transplant Dietitian [CCTD], Nutrition published October 4, 2016 in the Fed-
dietetics is composed of statutory and Wound Care Certified [NWCC], and eral Register, now “allows the attending
individual components, includes the Certified Wound Specialist [CWS]). The physician to delegate to a qualified
code(s) of ethics (eg, Academy/CDR, Scope of Practice Decision Algorithm dietitian or other clinically qualified
other national or international organi- (www.eatrightpro.org/scope) guides an nutrition professional the task of pre-
zations, and/or employers code of RDN through a series of questions to scribing a resident’s diet, including a
ethics), and encompasses the range of determine whether a particular activity therapeutic diet, to the extent allowed
roles, activities, practice guidelines, is within their scope of practice. The by State law” and permitted by the
and regulations within which RDNs algorithm is designed to assist an RDN facility’s policies.10 The qualified pro-
perform. For credentialed practitioners to critically evaluate their personal fessional must be acting within the
who practice in a state with profes- knowledge, skill, experience, judg- scope of practice as defined by state
sional licensure or certification, scope ment, and demonstrated competence law; and is under the supervision of
of practice is typically established using criteria resources.6 the physician that may include, for
within the practice act and associated The Centers for Medicare and example, countersigning the orders
regulations, and interpreted and Medicaid Services (CMS), Department written by the qualified dietitian or
controlled by the agency or board that of Health and Human Services, Hospi- clinically qualified nutrition profes-
regulates the practice of the profession tal7 and Critical Access Hospital8 Con- sional. RDNs who work in long-term
in a given state.5 An RDN’s statutory ditions of Participation allow a hospital care facilities should review the Aca-
scope of practice can delineate the and its medical staff the option of demy’s updates on CMS that
services an RDN is authorized to including RDNs or other clinically outline the regulatory changes to
perform in a state where a practice act qualified nutrition professionals within §483.60 Food and Nutrition Services
or certification exists. For more infor- the category of “non-physician practi- (www.eatrightpro.org/practice/quality-
mation, see www.eatrightpro.org/ tioners” eligible for ordering privileges management/national-quality-accredi
advocacy/licensure/licensure-map. for therapeutic diets and nutrition- tation-and-regulations/centers-for-
The RDN’s individual scope of prac- related services if consistent with medicare-and-medicaid-services). Re-
tice is determined by education, state law and health care regulations. view the state’s long-term care
training, credentialing, experience, and RDNs in hospital settings interested in regulations to identify potential bar-
demonstrating and documenting obtaining ordering privileges must re- riers to implementation; and identify
competence to practice. Individual view state laws (eg, licensure, certifi- considerations for developing the
scope of practice in nutrition and di- cation, and title protection), if facility’s processes with the medical
etetics has flexible boundaries to cap- applicable, and health care regulations director and for orientation of
ture the breadth of the individual’s to determine whether there are any attending physicians. The CMS State
professional practice. Professional barriers or state-specific processes that Operations Manual, Appendix PP-
advancement beyond the core educa- must be addressed. For more informa- Guidance for Surveyors for Long-Term
tion and supervised practice to qualify tion, review the Academy’s practice Care Facilities contains the revised
for the RDN credential provides RDNs tips that outline the regulations and regulatory language (new revisions are
practice opportunities, such as implementation steps for obtaining italicized and in red color).11 CMS
expanded roles within an organization ordering privileges (www.eatrightpro. periodically revises the State Opera-
org/dietorders/). For assistance, refer tions Manual Conditions of Participa-
questions to the Academy’s State Affil- tion; obtain the current information at
All registered dietitians are nutrition- iate organization. www.cms.gov/files/document/som107
ists—but not all nutritionists are regis- Medical staff oversight of an RDN(s) appendicestoc.pdf.
tered dietitians. The Academy’s Board of occurs in 1 of 2 ways. A hospital has the
Directors and Commission on Dietetic regulatory flexibility to appoint an
Registration have determined that ACADEMY QUALITY AND
RDN(s) to the medical staff and grant
those who hold the credential Regis-
tered Dietitian (RD) may optionally use the RDN(s) specific nutrition ordering PRACTICE RESOURCES
“Registered Dietitian Nutritionist” (RDN). privileges, or can authorize the The Academy’s Revised 2017 SOP in
The 2 credentials have identical mean- ordering privileges without appoint- Nutrition Care and SOPP for RDNs3
ings. In this document, the authors have ment to the medical staff. To comply reflect the minimum competent level
chosen to use the term RDN to refer to with regulatory requirements, an of nutrition and dietetics practice and
both registered dietitians and registered
RDN’s eligibility to be considered for professional performance. The core
dietitian nutritionists.
ordering privileges must be through standards serve as blueprints for the
2072 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS October 2021 Volume 121 Number 10
FROM THE ACADEMY
development of focus area SOP and THREE LEVELS OF PRACTICE nutrition and dietetics practice is a
SOPP for RDNs in competent, profi- The Dreyfus model15 identifies levels of defined area of practice that requires
cient, and expert levels of practice. proficiency (novice, advanced focused knowledge, skills, and experi-
The SOP in Nutrition Care is beginner, competent, proficient, and ence that apply to all levels of prac-
composed of 4 standards consistent expert) (refer to Figure 3) during the tice.17 A competent practitioner who
with the Nutrition Care Process (NCP) acquisition and development of has achieved credentialing as an RDN
and clinical workflow elements as knowledge and skills. The first 2 levels and is starting in professional employ-
applied to the care of patients/clients/ are components of the required di- ment consistently provides safe and
populations in all settings.12 The SOPP dactic education (novice) and super- reliable services by employing appro-
consist of standards representing 6 vised practice experience (advanced priate knowledge, skills, behavior, and
domains of professional performance: beginner) that precede credentialing values in accordance with accepted
Quality in Practice, Competence and for nutrition and dietetics practi- standards of the profession; acquires
Accountability, Provision of Services, tioners. Upon successfully attaining the additional on-the-job skills; and en-
Application of Research, Communica- RDN credential, a practitioner enters gages in tailored continuing education
tion and Application of Knowledge, professional practice at the competent to further enhance knowledge, skills,
and Utilization and Management of level and manages their professional and judgment obtained in formal edu-
Resources. The SOP and SOPP for development to achieve individual cation.17 A general practice RDN can
RDNs are designed to promote the professional goals. This model is help- include responsibilities across several
provision of safe, effective, efficient, ful in understanding the levels of areas of practice, including, but not
equitable, and quality food and practice described in the SOP and SOPP limited to, community; clinical;
nutrition care and services; for RDNs in Nutrition Support. In consultation and business; research;
facilitate evidence-based practice; Academy focus areas, the 3 levels of education; and food and nutrition
and serve as a professional evaluation practice are represented as competent, management.
resource. proficient, and expert. For delivery of quality and safe
These focus area standards for RDNs nutrition support therapy (enteral
in nutrition support provide a guide nutrition [EN] or parenteral nutrition
for self-evaluation and expanding [PN]), specific knowledge and skills are
practice, a means of identifying areas With safety and evidence-based prac- required when providing care and ser-
for professional development, and a tice17 as guiding factors when working vices to patients/clients needing nutri-
tool for demonstrating competence in with patients/clients/customers/pop- tion support therapy. RDNs with
ulations, the RDN identifies the level of
delivering nutrition support care and limited experience providing EN and/or
evidence, clearly states research limita-
services. They are used by RDNs to tions, provides safety information from PN need to explore options for
assess their current level of practice reputable sources, and describes the increasing knowledge and skills,
and to determine the education and risk of the intervention(s), when particularly with PN, a high-risk
training required to maintain currency applicable. medication according to the Institute
in their focus area and advancement to The Academy offers the Evidence for Safe Medication Practices.18 More
Analysis Library (www.andeal.org/) as a
a higher level of practice. In addition, in-depth knowledge is needed in areas
resource, which provides a synthesis of
the standards can be used to assist systematic reviews on a variety of such as PN indications,19 PN venous
RDNs in general clinical practice with nutrition and dietetics topics, such as access, PN ordering, fluid and electro-
maintaining minimum competence in malnutrition in older adults, hydration, lyte management, electrolyte disor-
the focus area, and by RDNs tran- and preterm infant enteral nutrition ders, micronutrient requirements, and
sitioning their knowledge and skills to guideline. The RDN is responsible for drugenutrient interactions, as well as
searching literature and assessing the
a new focus area of practice. Like the monitoring for and preventing com-
level of evidence to select the best
Academy’s core SOP in Nutrition Care available evidence to inform recom- plications (eg, refeeding syndrome20).
and SOPP for RDNs,3 the indicators (ie, mendations. RDNs must evaluate and The RDN entering into the area of
measurable action statements that understand the best available evidence nutrition support should seek out a
illustrate how each standard can be in order to converse authoritatively with more experienced RDN in nutrition
applied in practice) (see Figures 1 and the interprofessional team and support therapies as a mentor;
adequately involve the patient/client/
2, available at www.jandonline.org or reference Figure 4 for mentorship op-
customer/population in shared decision
https://onlinelibrary.wiley.com/journal/ making. portunities and programs. The
19412452) for the SOP and SOPP for competent-level RDN will gain crucial
RDNs in Nutrition Support were revised knowledge for safe and quality nutri-
with input and consensus of content tion support practice by reading arti-
experts representing diverse practice and cles and books, attending webinars or
geographic perspectives. The SOP and Competent Practitioner conferences related to nutrition sup-
SOPP for RDNs in Nutrition Support In nutrition and dietetics, a competent port, and accessing the Academy and
were reviewed and approved by the practitioner is an RDN who is either ASPEN resources in Figure 4.
Executive Committee of the DNS just starting practice after having ob-
DPG, the ASPEN Clinical Practice Com- tained RDN registration by CDR or an Proficient Practitioner
mittee and Board of Directors, and experienced RDN recently transitioning A proficient practitioner is generally 3
the Academy Quality Management their practice to a new focus area of or more years beyond RDN credential-
Committee. nutrition and dietetics. A focus area of ing and entry into the profession and
October 2021 Volume 121 Number 10 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2073
FROM THE ACADEMY
Standards of Practice (SOP) are authoritative statements that describe practice demonstrated through nutrition assessment, nutrition diagnosis
(problem identification), nutrition intervention (planning, implementation), and outcomes monitoring and evaluation (4 separate standards)
and the responsibilities for which RDNs are accountable. The SOP for RDNs in Nutrition Support presuppose that the RDN uses critical thinking
skills; analytical abilities; theories; best-available research findings; current accepted nutrition, dietetics, and medical knowledge; and the
systematic holistic approach of the nutrition care process as they relate to the application of the standards. Standards of Professional
Performance (SOPP) for RDNs in Nutrition Support are authoritative statements that describe behavior in the professional role, including
activities related to Quality in Practice; Competence and Accountability; Provision of Services; Application of Research; Communication and
Application of Knowledge; and Utilization and Management of Resources (6 separate standards).
SOP and SOPP are complementary standards and serve as evaluation resources. All indicators may not be applicable to all RDNs’ practice or to all
practice settings and situations. RDNs operate within the directives of applicable federal and state laws and regulations, as well as policies and
procedures established by the organization in which they are employed. To determine whether an activity is within the scope of practice of
the RDN, the practitioner compares their knowledge, skill, experience, judgment, and demonstrated competence with the criteria necessary to
perform the activity safely, ethically, legally, and appropriately. The Academy’s Scope of Practice Decision Algorithm is specifically designed to
assist practitioners with this process.
The term patient/client is used in the SOP as a universal term as these Standards relate to direct provision of nutrition care and services. Patient/client
could also mean client/patient, resident, participant, consumer, or any individual or group who receives nutrition support therapy care and services.
Customer is used in the SOPP as a universal term. Customer could also mean client/patient, client/patient/customer, participant, consumer, or
any individual, group, or organization to which the RDN provides services. These services are provided to individuals of all ages. The SOP and SOPP
are not limited to the clinical setting. In addition, it is recognized that the family and caregiver(s) of patient/clients of all ages, including individuals
with special health care needs, play critical roles in overall health and are important members of the team throughout the assessment and
intervention process. The term appropriate is used in the standards to mean: Selecting from a range of best practice or evidence-based possibilities,
one or more of which would give an acceptable result in the circumstances.
Each standard is equal in relevance and importance and includes a definition, a rationale statement, indicators, and examples of desired
outcomes. A standard is a collection of specific outcome-focused statements against which a practitioner’s performance can be assessed. The
rationale statement describes the intent of the standard and defines its purpose and importance in greater detail. Indicators are measurable
action statements that illustrate how each specific standard can be applied in practice. Indicators serve to identify the level of performance of
competent practitioners and to encourage and recognize professional growth.
Standard definitions, rationale statements, core indicators, and examples of outcomes found in the Academy of Nutrition and Dietetics: Revised
2017 SOP in Nutrition Care and SOPP for RDNs have been adapted to reflect 3 levels of practice (competent, proficient, and expert) for RDNs
in nutrition support (see image below). In addition, the core indicators have been expanded to reflect the unique competence expectations
for the RDN providing nutrition support therapy.
Standards described as proficient level of practice in this document are not equivalent to the National Board for Nutrition Support Certification,
Certified Nutrition Support Clinician (CNSC). Rather, the CNSC designation recognizes the skill level of an RDN who has developed and
demonstrated through successful completion of the certification examination, nutrition support knowledge and application beyond the
competent practitioner and demonstrates, at a minimum, proficient-level skills. An RDN with a CNSC designation is an example of an RDN
who has demonstrated additional knowledge, skills, and experience in nutrition support by the attainment of a specialist credential.
Figure 3. Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent,
Proficient, and Expert) in Nutrition Support. Image adapted from the Dietetics Career Development Guide, with permission.16
FROM THE ACADEMY
Resource Address Description

Academy of Nutrition and Dietetics (Academy) Resources
Academy of Nutrition and https://www.dnsdpg.org/ This DPG focuses on the science and practice of
Dietetics Dietitians in enteral and parenteral nutrition to provide
Nutrition Support Dietetic evidence-based nutrition support therapy to
Practice Group (DNS DPG) individuals throughout the lifespan. The DPG
provides resources to its members such as a
newsletter, educational opportunities such as the
DNS store, webinars with continuing education,
symposium, podcasts, and a mentorship program.
Academy of Nutrition and www.andeal.org This website provides evidence-based nutrition
Dietetics Evidence Analysis practice guidelines and systematic reviews
Library concerning nutrition support and related topics,
such as malnutrition in older adults, cystic fibrosis,
and preterm infant enteral nutrition.
Case Study: RDN to Write https://www.eatrightstore.org/ “This case study explores the situation in which a
Independent Parenteral product-type/case-studies-and- registered dietitian nutritionist requests privileges to
Nutrition (PN)/Enteral practice-tips/case-study- write independent orders for parenteral nutrition and
Nutrition (EN) Orders independent-parenteral-nutrition- enteral nutrition. Guidance, resources and options are
and-enteral-nutrition-orders provided that can be used to evaluate whether the
RDN can safely and effectively provide an expanded
practice skill and advance individual practice.”
Clinical Malnutrition https://www.eatrightpro.org/ This webpage includes information for RDNs
practice/practice-resources/ including the Malnutrition Quality Improvement
clinical-malnutrition Initiative (MQii), malnutrition resources from the
Academy (eg, malnutrition coding, nutrition-
focused physical exam training), and malnutrition
resources from other organizations (eg, Canadian
Malnutrition Task Force, Defeat Malnutrition Today).
Enteral Feeding: What I Wish https://www.eatrightstore.org/cpe- This webinar outlines gastrointestinal physiology in the
I Knew When I Started Out in opportunities/online-courses/ context of enteral nutrition delivery and dispels many
Practice enteral-feeding-what-i-wish-i- myths surrounding signs and symptoms of what is
knew-when-i-started-out-in- referred to as “intolerance” of enteral nutrition.
practice
Mentoring or Career https://www.eatrightpro.org/ This webpage provides mentoring resources specific to
Guidance Opportunities membership/academy-groups/ the Academy’s DPGs. This page includes a link to the
dietetic-practice-groups/ Academy eMentoring and Mentoring Resources page,
mentoring-or-career-guidance- which provides resources for identifying a mentor and
opportunities building mentor/mentee relationships. In addition,
Academy members may enroll in Mentor Match,
which matches Academy members with a mentor or
mentee who best fits the professional areas of interest,
communication style, and availability.
Optimizing the Transition https://www.eatrightstore.org/ This education session discusses the RDN’s role in
from Acute to Home Enteral collections/fnce-2019/194- establishing an appropriate care plan and how that
Nutrition optimizing-the-transition-from- plan can be continued at home for a smooth and
acute-to-home-enteral-nutrition effective continuum of care working with the
interprofessional team.
(continued on next page)

Figure 4. Resources for Registered Dietitian Nutritionists (RDNs) in Nutrition Support (not all-inclusive).
FROM THE ACADEMY

Pocket Guide to Enteral https://www.eatrightstore.org/ This guide provides comprehensive information
Nutrition, 2nd edition product-type/pocket-guides/ regarding enteral nutrition, such as indications/
academy-pocket-guide-to- contraindications, patient assessment, enteral
enteral-nutrition-2ed access, and feeding initiation, advancement, and
transition. It also includes information about how to
apply the Nutrition Care Process as it relates to
enteral nutrition.
Pocket Guide to Parenteral https://www.eatrightstore.org/ This guide provides information on indications for
Nutrition, 2nd edition product-type/ebooks/pocket- parenteral nutrition, determining parenteral nutrition
guide-to-parenteral-nutrition- nutrients, vascular access, initiation and
second-edition-ebook advancement of parenteral nutrition, patient/client
monitoring, and coordination of care. This resource
also includes information about how to apply the
Nutrition Care Process to parenteral nutrition.
American Society for Parenteral and Enteral Nutrition (ASPEN) Resources
Appropriate Dosing for http://www.nutritioncare.org/ This 3-page tool provides basic guidelines for dosing
Parenteral Nutrition: ASPEN uploadedFiles/Documents/ of macro- and micronutrients for adult, neonatal,
Recommendations Guidelines_and_Clinical_ and pediatric patients/clients receiving parenteral
Resources/PN%20Dosing%201- nutrition. It is to be used to assure that minimum
Sheet-FINAL.pdf nutrient needs are met to prevent deficiencies,
particularly in the case of drug shortages.
ASPEN eLearning Center https://aspen.digitellinc.com/aspen/ This website provides the various eLearning resources
related to enteral and parenteral nutrition provided
by ASPEN. Resources include items such as journal
continuing education, webinar recordings,
podcasts, conference recordings, and online
courses.
ASPEN Enteral Nutrition http://www.nutritioncare.org/ This book gives evidenced-based practice
Handbook, 2nd edition ENHandbook/ recommendations for the clinician providing
enteral nutrition. It delivers comprehensive
information on enteral nutrition for the adult and
pediatric patient/client.
ASPEN Fluids, Electrolytes, https://portal.nutritioncare.org/ This book provides guidance on issues such as
and Acid-Based Disorders bookstore-details?id¼0eac1493-8 managing electrolyte balance, treatment of sodium
Handbook, 2nd edition 0e3-4429-9fd5-3d2fe08522d4 disorders, and maintenance of hydration. This book
includes information on adult and pediatric
patients/clients.
ASPEN Guidelines and https://www.nutritioncare.org/ This website provides guidelines, publications, and
Clinical Resources guidelines_and_clinical_ clinical resources to assist in providing safe, quality
resources/ nutrition care to patients/clients. Resources include
books, journals, enteral and parenteral nutrition
resources, Malnutrition Solutions Center, and
Clinical Practice Library, which includes clinical
guidelines, consensus recommendations, position
papers, and standards.

Figure 4. (continued) Resources for Registered Dietitian Nutritionists (RDNs) in Nutrition Support (not all-inclusive).
FROM THE ACADEMY

ASPEN Nutrition Support http://www.nutritioncare.org/NSFC/ This course provides the attendee with the
Fundamentals Course fundamentals of nutrition support and is used in
preparation for obtaining the Nutrition Support
Certification as a Certified Nutrition Support
Clinician. It is a tool also used to identify personal
knowledge gaps and guide future areas of learning.
A.S.P.E.N. Parenteral https://portal.nutritioncare.org/ This resource is designed to improve competency
Nutrition Workbook bookstore-details?id¼37899a99- with parenteral nutrition prescribing and order
aa57-4aa6-8564-b0ee552910b9 writing. This practical workbook provides case
studies to guide the reader through real-world
clinical situations. It is intended for varying levels of
practice, including students.
Guidebook on Enteral http://www.nutritioncare.org/ This guidebook provides comprehensive information
Medication Administration ENMedicationGuidebook/ on medication delivery via feeding tubes. It gives
providers such as RDNs, pharmacists, nurses, and
physicians crucial information on how to give
medication via feeding tubes.
The ASPEN Adult Nutrition https://store.ashp.org/Default.aspx? This book provides information regarding the
Support Core Curriculum, 3rd TabID¼251&productId¼6178288 fundamentals of nutrition support. It also gives
edition 04 nutrition support recommendations for certain
medical conditions, as well as case scenarios to
facilitate learning.
The ASPEN Parenteral https://portal.nutritioncare.org/ This book provides information on the fundamentals
Nutrition Handbook, 3rd bookstore-details?id¼9c8a6b20-5 of parenteral nutrition including, but not limited to,
edition f45-48e7-8d7e-892a615886 competency, order review, compounding, and
ff&index¼26&reload¼timezone management of drug shortages.
The A.S.P.E.N. Pediatric https://portal.nutritioncare.org/ This Core Curriculum provides detailed information
Nutrition Support Core bookstore-details?id¼90ea43d1- about pediatrics from infancy through adolescence.
Curriculum, 2nd edition dae3-4914-baf7-47fb51528b48 It contains chapters that explain the use of enteral
and parenteral nutrition in the pediatric population,
such as how to determine nutrient needs, how to
select the most appropriate access device,
administration of nutrition support, and monitoring
the effectiveness of nutrition support.
Professional Websites
Clinical Care Nutrition https://www.criticalcarenutrition. Clinical Care Nutrition aims to improve nutrition
com/ therapies in the critical care setting through
research that will translate into improved clinical
outcomes for critically ill patients.
European Society for Clinical www.espen.org This European organization provides extensive
Nutrition and Metabolism information regarding the provision of enteral and
(formerly European Society parenteral nutrition. Resources include journals,
for Parenteral and Enteral trainings, electronic video library, books, and
Nutrition) guidelines.

FROM THE ACADEMY

National Board of Nutrition http://www.nutritioncare.org/ The Certified Nutrition Support Clinician (CNSC)
Support Certification nbnsc/ certification is available to RDNs, nurses,
pharmacists, and physicians. It signifies these
practitioners as proficient to practice in the area of
nutrition support. An examination must be
passed to receive this certification, and re-
examination is required every 5 years to maintain
the credential.
North American Society for www.naspghan.org This organization provides information
Pediatric Gastroenterology, regarding pediatric gastroenterology,
Hepatology & Nutrition hepatology, and nutrition in health and
disease. Resources they provide include a journal,
annual meeting, mentorship program, and
advocacy efforts.
Society of Critical Care www.sccm.org This organization provides information
Medicine regarding treatment of critically ill patients and
develops guidelines that may be helpful to the
nutrition support clinician. Resources also
include webcasts, conferences, and knowledge
education groups.
consistently provides safe and reliable and dietetics. Expert-level achieve- engagements, and serve the profession
services; has obtained operational job ment is acquired through ongoing by participating in Academy and ASPEN
performance skills; and is successful in critical evaluation of practice and organizations at the local, state, and/or
the RDN’s chosen focus area of practice. feedback from others. The individual at national level. Expert-level RDNs
The proficient practitioner demon- this level strives for additional knowl- participate and lead research and/or
strates additional knowledge, skills, edge, experience, and training. An quality improvement projects to assess
judgment, and experience in a focus expert has the ability to quickly iden- the efficacy of services and contribute
area of nutrition and dietetics practice. tify “what” is happening and “how” to to the nutrition support body of
An RDN may acquire specialist cre- approach the situation. Experts easily knowledge, thus promoting and
dentials, if available, to demonstrate use nutrition and dietetics skills to improving evidence-based practice in
proficiency in a focus area of practice.17 become successful through demon- nutrition support.
The proficient-level RDN in nutrition strating quality practice and leader- These Standards, along with the
support has gained more nutrition ship, and to consider new Academy/CDR Code of Ethics,3 answer
support-related clinical skills and opportunities that build on nutrition the questions: Why is an RDN uniquely
knowledge above that of a competent and dietetics.17 An expert practitioner qualified to provide nutrition support
practitioner and functions with more may have an expanded or specialist care and services? What knowledge,
autonomy in managing patients role, or both, and may possess an skills, and competencies does an RDN
requiring EN or PN. The proficient advanced credential(s), such as the need to demonstrate for the provision
practitioner has sufficient, or is work- CNSC, RDN-AP, and/or CSPCC. Gener- of safe, effective, efficient, equitable,
ing towards sufficient, knowledge and ally, the practice is more complex, and and quality nutrition support care and
qualifications through continuing edu- the practitioner has a high degree of service at the competent, proficient,
cation or practice hours in nutrition professional autonomy and re- and expert levels?
support in order to qualify for the sponsibility. Expert-level RDNs in
CNSC,21 RDN-AP, or CSPCC. nutrition support serve as a principal
source of information and guidance for OVERVIEW
Expert Practitioner RDN colleagues and interprofessional Nutrition support therapy is defined as
An expert practitioner is an RDN team members. They promote the providing enteral or parenteral nutri-
recognized within the profession and practice and expertise needed for tion with therapeutic intent or to treat
has mastered the highest degree of quality nutrition support practice or prevent malnutrition.22-26 Nutrition
skill in, and knowledge of, nutrition through publications, speaking support is a therapy used with
FROM THE ACADEMY
individuals of all ages, diseases, and results, conduct nutrition assessments therapy. RDNs may also collaborate
conditions. Health care practitioners with nutrition-focused physical exam- with their information technology
strive to meet the nutritional re- inations,28,29 confer with interprofes- teams to advance personalized nutri-
quirements of individuals who are sional team members, determine tion efforts.44-46 Personalized nutrition
unable to meet nutrient needs with plan(s) of care, and provide ongoing refers to the use of individual measur-
oral intake alone, have intestinal fail- monitoring and adjustments to the able data to affect nutritional status or
ure, and/or are unable to meet hydra- plan of care. With privileging5,30 and/or outcomes, such as continuous glucose
tion needs for a variety of reasons. organization-approved policies and monitoring or indirect calorimetry.43
RDNs, integral members of the nutri- protocols, RDNs place enteral feeding RDNs may also collaborate with their
tion support or interprofessional tubes31,32 and initiate, implement, and/ information technology team to
team,22 provide needed expertise on or adjust protocol- or physician-order- enhance electronic health record
the identification of risk or presence of driven EN- or PN-related plans. workflow and functionality and
malnutrition, macro- and micro- There are a variety of patients/clients improve nutrition support safety.45,46
nutrient requirements, type of nutri- seen by RDNs in nutrition support who Both the Academy47 and ASPEN48
tion support therapy (eg, enteral or span all ages (including neonatal, pe- have evidence-based practice guide-
parenteral), and appropriate nutrition diatric,33,34 and adult35) and diseases/ lines and position papers related to
support access and route (eg, nasogas- conditions. Therefore, a person- nutrition support to help guide RDNs in
tric vs nasojejunal or tunneled catheter centered approach is critical to care. nutrition support practice. These
vs port). RDNs must have the knowledge, skill, guidelines cover a variety of topics,
and experience in the application of including malnutrition in older
principles and guidelines in delivering adults,49 selection and care of central
Enteral nutrition is a delivery system nutrition support, along with general venous access devices for adult home
“providing nutrition directly into the knowledge of all potential comorbid- parenteral nutrition administration,50
gastrointestinal tract via a tube, cath- ities of a patient/client, in order to nutrition support in the pediatric crit-
eter, or stoma that bypasses the oral appropriately address and provide ically ill patient,51 and nutrition sup-
cavity.”17,22 quality nutrition care and services or port in the adult critically ill patient,52
“Parenteral nutrition is the intrave- know when to confer with or refer to use of visceral protein markers53,
nous administration of nutrients such as another provider. among others. ASPEN also publishes
amino acids, carbohydrate, lipid, and Since patients/clients requiring discipline-based standards for nurses,54
added vitamins and minerals delivered
via central or peripheral route. Central nutrition support therapy present with pharmacists,55 and physicians.56 Other
means parenteral nutrition delivered varied and complex treatment issues, resources for RDNs in nutrition
into a large-diameter vein, usually the the RDN must consider the ethical im- support can be found in Figure 4.
superior vena cava adjacent to the right plications36-38 of nutrition and hydra- The DNS DPG57 and ASPEN58 provide
atrium. Peripheral means parenteral tion,39,40 particularly in certain an abundance of information and re-
nutrition delivered into a peripheral populations, such as those with de- sources for RDNs in nutrition support.
vein, usually of the hand or
forearm.”17,22 mentia41 or receiving palliative42 or The DNS DPG offers resources such as
end-of-life care. Care decisions need to the Support Line newsletter, webinars,
reflect the wishes of the patient/client symposium, videos, toolkits, mentor-
and/or family/surrogate decision- ship program, podcast recordings, and
An RDN’s practice in nutrition sup- maker, consistent with an advanced an online forum. ASPEN resources
port varies according to practice setting, directive that may be in place. include webinars, an eLearning Center,
the number of individuals requiring The RDN practicing in nutrition an online community, conference,
specialized nutrition support, and role support collaborates with the inter- books, journals (Nutrition in Clinical
and responsibilities. The primary setting professional team that includes multi- Practice and Journal of Parenteral and
is acute care hospitals (eg, academic, ple disciplines according to the specific Enteral Nutrition), and a Malnutrition
community, and critical access). Pop- needs of the patient/client. Core nutri- Solution Center. The DNS DPG and
ulations encompass adults, pediatric tion support team22 members, in ASPEN offer volunteer opportunities
and neonatal, surgical, oncology, renal, addition to the RDN, include a physi- that promote development of profes-
gastrointestinal, and transplant, among cian(s), pharmacist, and nurse. Other sional relationships.
others. In addition, RDNs practicing in professionals, such as physician assis-
nutrition support work in ambulatory/ tant, nurse practitioner, respiratory
outpatient settings, home care, and therapist, speech language pathologist, ACADEMY AND ASPEN REVISED
alternate site care (ie, long-term acute and social worker, may be included in 2021 SOP AND SOPP FOR RDNs
care, rehabilitation, and skilled/long- the team to meet the care goals and (COMPETENT, PROFICIENT, AND
term care).27 RDNs practicing in nutri- outcomes. An interprofessional EXPERT) IN NUTRITION
tion support therapy may conduct approach has been shown to enhance SUPPORT
research, teach, consult, and write for quality of care, improve patient safety An RDN can use the Academy and
peer-reviewed professional publications and outcomes,24 and reduce health ASPEN Revised 2021 SOP and SOPP for
(solely or in combination with a clinical care costs.43 Within the interprofes- RDNs (Competent, Proficient, and
practice). sional team, the RDN is a key resource Expert) in Nutrition Support (see
In clinical settings, RDNs in nutrition on medical nutrition therapy and Figures 1 and 2, available at www.
support evaluate nutrition screening various aspects of nutrition support jandonline.org or https://onlinelibrary.
FROM THE ACADEMY
wiley.com/journal/19412452, and profession or may be an experienced nutrition support RDNs in various dis-
Figure 3) to: RDN, has a breadth of knowledge in ciplines and practice settings. Expert
nutrition and dietetics and may have RDNs, with their extensive experience
identify the competencies
proficient or expert knowledge/prac- and ability to see the significance and
needed to provide nutrition
tice in another focus area. However, the meaning of nutrition support within a
support care and services;
RDN new to the focus area of nutrition contextual whole, are fluid and flexible,
self-evaluate whether they have
support must accept the challenge of and have considerable autonomy in
the appropriate knowledge,
becoming familiar with the body of practice. They not only develop and
skills, and judgment to provide
knowledge, required clinical judgment implement nutrition support services;
safe, effective, equitable, and
skills, practice guidelines, and available they also manage, drive, and direct
quality nutrition support care
resources to support and ensure qual- clinical care; conduct and collaborate
and service for their level of
ity nutrition supporterelated nutrition in research and advocacy; work for
practice;
and dietetics practice. Specific to pharmaceutical companies; accept or-
identify the areas in which
nutrition support, RDNs at the compe- ganization leadership roles; engage in
additional knowledge, skills, and
tent level are able to independently scholarly work; guide interprofessional
experience are needed to prac-
complete nutrition assessments for teams; and lead the advancement of
tice at the competent, proficient,
patients with a variety of co-morbid nutrition support practice. RDNs in
or expert level of nutrition sup-
conditions, calculate macronutrient nutrition support practicing at the
port practice;
needs to promote or sustain recovery, expert practitioner level are considered
provide a foundation for public
and recommend nutrition support experts in the field and incorporate, as
and professional accountability
regimens according to best practice appropriate and within state regula-
in nutrition support care and
and consistent with individualized care tions and organizational policies, skills
services;
plans. such as insertion of nasoenteric feeding
support efforts for strategic
At the proficient level, an RDN has tubes,31,59,60 and EN and PN order
planning, performance improve-
developed a more in-depth under- writing.5,30 RDNs with extensive expe-
ment, outcomes reporting, and
standing of nutrition support practice rience in the use of nutrition support
assist management in the plan-
and is more skilled at adapting and therapy, often with the CNSC, are
ning and communicating of
applying evidence-based guidelines leaders in the intensive care units or
nutrition support services and
and best practices than at the compe- other settings in which nutrition sup-
resources;
tent level. This RDN is able to modify port is administered. Nutrition care is
enhance professional identity
practice according to unique situations. person-centered and proactive in
and skill in communicating the
The RDN at the proficient level may identifying and addressing needs
nature of nutrition support care
possess a specialist credential(s). RDNs through the effective application of
and services;
in nutrition support practicing at the oral, enteral, and/or parenteral nutri-
guide the development of nutri-
proficient level may have obtained tion. The expert-level RDN may also be
tion support-related education
privileges or receive physician- serving as team coordinator or man-
and continuing education pro-
delegated orders to order and manage ager and/or leading an interprofes-
grams, job descriptions, practice
nutrition support therapies, and are sional team effort to measure and track
guidelines, protocols, clinical
able to manage a higher-volume, more outcomes data related to malnutri-
models, competence evaluation
complex patient load compared to the tion61 and other nutrition-related
tools, and career pathways; and
RDN at the competent level. Experi- quality measures.
assist educators and preceptors
enced RDNs in nutrition support may Indicators for the SOP and SOPP for
in teaching students and interns
also serve as a mentor or preceptor to RDNs in Nutrition Support are
the knowledge, skills, and com-
nutrition and dietetics students/interns measurable action statements that
petencies needed to work in
and/or a mentor to competent-level illustrate how each standard can be
nutrition support, and the un-
practitioners on management of pa- applied in practice (Figures 1 [SOP] and
derstanding of the full scope of
tients requiring nutrition support 2 [SOPP], available at www.jandonline.
this focus area of practice.
therapies. org and https://onlinelibrary.wiley.
At the expert level, the RDN thinks com/journal/19412452). Within the
APPLICATION TO PRACTICE critically about nutrition support, SOP and SOPP for RDNs in Nutrition
All RDNs, even those with significant demonstrates a more intuitive under- Support, an “X" in the competent col-
experience in other practice areas, standing of the practice area, displays a umn indicates that an RDN who is
must begin at the competent level range of highly developed clinical and caring for patients/clients is expected
when practicing in a new setting or technical skills, and formulates judg- to complete this activity and/or seek
new focus area of practice. At the ments acquired through a combination assistance to learn how to perform at
competent level, an RDN in nutrition of education, experience, and critical the level of the standard. A competent-
support is learning the principles that thinking. Essentially, practice at the level RDN in nutrition support could be
underpin this focus area and is devel- expert level requires the application of an RDN starting practice after regis-
oping knowledge, skills, judgment, and composite nutrition and dietetics tration or an experienced RDN who has
gaining experience for safe and effec- knowledge, with practitioners drawing recently assumed responsibility to
tive nutrition support practice. This not only on their practice experience, provide nutrition support care for pa-
RDN, who may be new to the but also on the experience of the tients/clients. Examples of patients/
FROM THE ACADEMY
clients evaluated by a competent-level practice and professional performance In some instances, components of
RDN include those with malnutri- and set goals for professional develop- the SOP and SOPP for RDNs in Nutrition
tion,62-66 gastrointestinal disorders (eg, ment. This self-appraisal also enables Support do not specifically differentiate
inflammatory bowel disease), cystic nutrition support RDNs to better use between proficient-level and expert-
fibrosis,67 and dysphagia.68-71 these Standards as part of the Profes- level practice. In these areas, it re-
An “X" in the proficient column in- sional Development Portfolio recertifi- mains the consensus of the content
dicates that an RDN who performs at cation process,75 which encourages experts that the distinctions are subtle
this level has a deeper understanding CDR-credentialed nutrition and di- and captured in the knowledge, expe-
of nutrition support therapy and has etetics practitioners to incorporate rience, and intuition demonstrated in
the ability to modify or guide therapy self-reflection and learning needs the context of practice at the expert
to meet the needs of patients/clients in assessment for development of a level, which combines dimensions of
various situations (eg, patients/clients learning plan for improvement and understanding, performance, and value
with diabetes,72 renal conditions,73 commitment to lifelong learning. CDR’s as an integrated whole.79 A wealth of
electrolyte disturbances, acute pulmo- 5-year recertification cycle in- knowledge is embedded in the experi-
nary failure on a ventilator, compli- corporates the use of essential practice ence, discernment, and practice of
cated wounds, or neonates on enteral competencies for determining profes- expert-level RDN practitioners. The
nutrition).33,34,74 sional development needs.76 In the experienced practitioner observes
An “X" in the expert column indicates 3-step process, the credentialed prac- events, analyzes them to make new
that the RDN who performs at this level titioner accesses the Competency Plan connections between events and ideas,
possesses a comprehensive under- Builder77 (step 1), which is a digital and produces a synthesized whole. The
standing of nutrition support therapy tool that assists practitioners in knowledge and skills acquired through
and a highly developed range of skills creating a continuing education practice will continually expand and
and judgments acquired through a learning plan. It helps identify focus mature. The SOP and SOPP indicators
combination of experience and educa- areas during each 5-year recertification are refined with each review of these
tion. The expert RDN builds and main- cycle for verified CDR-credentialed Standards as expert-level RDNs sys-
tains the highest level of knowledge, nutrition and dietetics practitioners. tematically record and document their
skills, and behaviors, including leader- The Activity Log (step 2) is used to log experiences, often through use of ex-
ship, vision, and credentials. and document continuing professional emplars. Exemplary actions of individ-
Standards and indicators presented education during the 5-year period. ual nutrition support RDNs in practice
in Figure 1 and Figure 2 (available at The Professional Development Evalua- settings and professional activities that
www.jandonline.org and at https:// tion (step 3) guides self-reflection and enhance patient/client/population care
onlinelibrary.wiley.com/journal/19412452) assessment of learning and how it is and/or services, can be used to illus-
in boldface type originate from the applied. The outcome is a completed trate outstanding practice models (eg,
Academy’s Revised 2017 SOP in evaluation of the effectiveness of the DNS Distinguished Practice Award,80
Nutrition Care and SOPP for RDNs3 and practitioner’s learning plan and ASPEN Distinguished Nutrition Sup-
should apply to RDNs in all 3 levels. continuing professional education. The port Dietitian: Advanced Clinical Prac-
Additional indicators not in boldface self-assessment information can then tice Award,81 ASPEN Distinguished
type developed for this focus area are be used in developing the plan for the Nutrition Support Dietitian Service
identified as applicable to all levels of practitioner’s next 5-year recertifica- Award,81 Fellow of ASPEN,81 and
practice. Where an “X" is placed in all tion cycle. For more information, Fellow of the Academy82).
3 levels of practice, it is understood see www.cdrnet.org/competencies-for-
that all RDNs in nutrition support are practitioners.
accountable for practice within each of RDNs are encouraged to pursue addi- FUTURE DIRECTIONS
these indicators. However, the depth tional knowledge, skills, and training, The SOP and SOPP for RDNs in Nutri-
with which an RDN performs each regardless of practice setting, to maintain tion Support are innovative and dy-
activity will increase as the individual currency and to expand individual scope namic documents. Future revisions will
moves beyond the competent level. of practice within the limitations of the reflect changes and advances in prac-
Several levels of practice are consid- legal scope of practice, as defined by state tice, changes to dietetics education
ered in this document; thus, taking a law, where applicable. RDNs are expected standards, regulatory changes, and
holistic view of the SOP and SOPP for to practice only at the level at which they outcomes of practice audits. Continued
RDNs in Nutrition Support is war- are competent, and this will vary clarity and differentiation of the 3
ranted. It is the totality of individual depending on education, training, and practice levels in support of safe,
practice that defines a practitioner’s experience.78 RDNs should collaborate effective, equitable, and quality prac-
level of practice and not any one in- with other RDNs in nutrition support to tice in nutrition support remains an
dicator or standard. gain and provide learning opportunities, expectation of each revision to serve
RDNs should review the SOP and promote consistency in practice, and tomorrow’s practitioners and their pa-
SOPP in Nutrition Support at deter- perpetuate alliances in continuous qual- tients, clients, and customers.
mined intervals to evaluate their indi- ity improvement and research. See To enhance competitiveness in to-
vidual focus area knowledge, skill, and Figure 5 for role examples of how RDNs day’s health care environment, RDNs
competence. Consistent self-evaluation in different roles, at different levels of may need to broaden their skill set
is important because it helps identify practice, can use the SOP and SOPP for with additional education (eg, master’s
opportunities to improve and enhance RDNs in Nutrition Support. in public health, doctorate in clinical
FROM THE ACADEMY
Role Examples of use of SOP and SOPP documents by RDNs in different practice rolesa
Clinical practitioner, acute An registered dietitian nutritionist (RDN) providing coverage on a general medical unit will
care settingeadult and now also be providing care to patients in the medical intensive care unit (ICU). Working with
pediatric an experienced colleague when needed, the RDN has managed short-term nutrition support
therapy for non-ICU patients but recognizes more in-depth knowledge and skills are needed
when caring for critically ill patients in an ICU setting. The RDN reviews the Standards of
Practice (SOP) and Standards of Professional Performance (SOPP) in Nutrition Support to
evaluate level of practice and competence. The RDN reviews the nutrition support-related
practice guidelines and seeks mentoring from an experienced nutrition support RDN who is
ideally a Certified Nutrition Support Clinician (CNSC) to discuss approach to care, decision-
making process for determining enteral nutrition (EN) vs parenteral nutrition (PN), and for
monitoring and adjusting nutrition care plan. The RDN identifies continuing education
opportunities to pursue to enhance skills and to help decide whether working toward
eligibility for the CNSC certification is a career goal.
Clinical practitioner, home An RDN with the CNSC certification working in nutrition support in an acute care hospital
care and alternate-site care decides to transition to a new opportunity with a home infusion company providing
nutrition support services to individuals of all ages in their homes or in an acute
rehabilitation, skilled, or long-term care facility. The RDN reviews the SOP and SOPP in
Nutrition Support and other focus areas (eg, Pediatric Nutrition, Nephrology Nutrition, Post-
Acute and Long-Term Care [PALTC]), position description and scope of work to determine
whether any new/enhanced knowledge or skills are needed. The company recently
implemented telehealth within its service lines to facilitate communications with health care
providers, clients/residents, and facilities using the company’s services. The RDN pursues
resources identified in the SOP and SOPP articles and continuing education opportunities,
including effective use of telehealth to enhance skills in this delivery method.
Clinical practitioner, PALTC An RDN working in a skilled nursing and long-term care facility observes an increase in the
number of new residents who require EN. The RDN refers to the SOP and SOPP in Nutrition
Support in addition to the SOP and SOPP in PALTC to enhance knowledge and skills to guide
assessment and plan of care decision making for these individuals. The RDN reviews the
resources identified in the SOP and SOPP articles and indicators to increase knowledge and
identify areas for continuing education. When applicable, the RDN contacts an RDN
colleague at the community hospital, who provides care for patients receiving nutrition
support therapy to gain ideas for care plans, the most appropriate enteral nutrition formula
on the facility’s formulary, determining supplemental water and vitamin/mineral
supplementation; and other types of adjustments that may be needed to support a
resident’s nutritional needs consistent with their wishes.
Manager, nutrition services A manager who oversees RDNs whose responsibilities include providing nutrition support
therapy to individuals with a variety of medical conditions considers the SOP and SOPP in
Nutrition Support when determining expertise at the program level, position descriptions,
career ladders, work assignments, and when evaluating competency and RDN staff needs
for additional knowledge and/or skills in nutrition support therapy. The manager recognizes
the SOP and SOPP in Nutrition Support along with other applicable focus area standards (eg,
pediatric nutrition, nephrology nutrition, diabetes care) as important tools for staff to use to
assess their knowledge, skills, and competencies; to identify personal performance plans;
and to guide quality improvement data collection and evaluation to optimize patient/client
outcomes.

Figure 5. Role examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian
Nutritionists (RDNs) (Competent, Proficient, and Expert) in Nutrition Support.
FROM THE ACADEMY
Role Examples of use of SOP and SOPP documents by RDNs in different practice rolesa
Community nutrition An RDN working in a WICb clinic notices an increase in the number of clients with specialized
practitioner, public health infant formula orders who receive the formula via tube feedings. Recognizing the need for
practitioner and desiring more knowledge about enteral nutrition in this population, the RDN uses the
SOP and SOPP in Nutrition Support and SOP and SOPP in Pediatric Nutrition to evaluate
their current knowledge and assessment skills and seeks out continuing-education
opportunities. The RDN identifies an experienced RDN within the local pediatric hospital/
outpatient facility who is willing to provide mentoring and guidance on complex cases that
are beyond the RDN’s current level of experience and competence.
Quality improvement An RDN working on their organization’s quality improvement team is actively working to
practitioner reduce the incidence of malnutrition in patients/clients receiving nutrition support. The RDN
uses the SOP and SOPP in Nutrition Support to review relevant resources related to
malnutrition and quality improvement and leverages practitioners working at the top of
their individual and statutory scope of practice. The RDN reviews the Academy of Nutrition
and Dietetics Malnutrition Quality Improvement Initiative (MQii) and ASPEN Malnutrition
Solutions Center resources for relevant background, identifies applicable nutrition-related
measures, gains buy-in from key stakeholders, and partners with other health care
professionals to execute sustainable solutions.
Faculty and preceptors, An RDN serving as a preceptor in a nutrition support rotation for an accredited nutrition and
nutrition and dietetics dietetics education program uses the SOP and SOPP in Nutrition Support to identify
education program appropriate learning activities for students/interns (eg, readings, written assignments,
clinical experiences, quality improvement activities, case studies, presentations, and/or
discussions with nutrition support practitioners).
a
For each role, the RDN updates their professional development plan to include applicable essential practice competencies for
nutrition support care and services.
b
WIC ¼ Special Supplemental Nutrition Program for Women, Infants, and Children.
Figure 5. (continued) Role examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered
Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Nutrition Support.
nutrition) and/or credentials (eg, CNSC, technologies, such as bedside ultra- applicable federal and state regulations
CSPCC, and/or RDN-AP) consistent with sound to assess muscle changes85; and facility accreditation standards.
personal interests and skills needed to leading nutrition support clinics to The SOP and SOPP for RDNs in Nutri-
address patient/client population assess adequacy and tolerance of tion Support are complementary doc-
needs and preferences and organiza- nutrition support therapies86; uments and are key resources for RDNs
tion objectives. Achieving certification providing education; demonstrating at all knowledge and performance
or other credentials is an assured way leadership in emergency planning for levels. These standards can and should
to demonstrate RDNs are equipped to natural disasters, product shortages; be used by RDNs in nutrition support
meet their next challenge, and to and using approved care protocols to daily practice who provide care to in-
expand options for future opportu- assess, monitor, maintain, and trou- dividuals to consistently improve and
nities. RDNs in nutrition support also bleshoot enteral access devices. appropriately demonstrate compe-
have the opportunity to strengthen the tence and value as providers of safe,
role and responsibilities of the profes- effective, equitable, and quality nutri-
sion through promotion of clinical SUMMARY tion and dietetics care and services.
privileging for ordering therapeutic RDNs face complex situations every These standards also serve as a pro-
diets and nutrition-related services, day. Addressing the unique needs of fessional resource for self-evaluation
including nutrition support therapies, each situation and applying standards and professional development for
when consistent with state law and appropriately is essential to providing RDNs specializing in nutrition support
health care regulations. Nutrition sup- safe, timely, person-centered quality practice. Just as a professional’s self-
port RDNs can advance nutrition and care and service. All RDNs are advised evaluation and continuing education
dietetics practice by assisting with to conduct their practice based on the process is an ongoing cycle, these
measurement and reporting of patient- most recent edition of the Code of standards are also a work in progress
related outcomes; increasing promo- Ethics for the Nutrition and Dietetics and will be reviewed and updated
tion and use of resources related to Profession, the Scope of Practice for every 7 years.
telehealth83,84; placing feeding RDNs, and the SOP in Nutrition Care Current and future initiatives of
tubes31,59,60; becoming trained on new and SOPP for RDNs, along with the Academy and ASPEN, as well as
FROM THE ACADEMY
advances in nutrition support care August 9, 2021, https://www.eatrightpro. 12. Swan WI, Vivanti A, Hakel-Smith NA, et al.
org/practice/code-of-ethics/what-is-the- Nutrition Care Process and Model update:
and services, will provide informa-
code-of-ethics. Toward realizing people-centered care
tion to use in future updates and in and outcomes management. J Acad Nutr
5. Academy of Nutrition and Dietetics
further clarifying and documenting Quality Management Committee. Acad- Diet. 2017;117(12):2003-2014.
the specific roles and responsibilities emy of Nutrition and Dietetics: Revised 13. The Joint Commission. Glossary, Compre-
of RDNs at each level of practice. As a 2017 Scope of Practice for the Registered hensive Accreditation Manual for Hospitals.
Dietitian Nutritionist. J Acad Nutr Diet. Joint Commission Resources; 2019.
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eatrightpro.org/scope. html.
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represent an important collaborative
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These standards have been formulated Orders. US Department of Health and
for use by individuals in self-evaluation, Accessed August 9, 2021, https://www.
Human Services, Centers for Medicare eatrightpro.org/practice/career-development/
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information presented in the standards W-Survey protocol, regulations and
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is not a substitute for the exercise of in Acute Care Settings. Institute for Safe
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AUTHOR INFORMATION
M. L. Corrigan works in Medical Affairs, Baxter Healthcare, Deerfield IL 60015 (at the time the manuscript was written, she was a clinical nutrition
manager, Cleveland Clinic, Cleveland, OH). E. Bobo is a dietitian clinic coordinator and a clinical dietitian, Nemours Children’s Specialty Care,
Jacksonville, FL. C. Rollins is a manager, Quality Programs, Option Care Health, Rochester, IL. K. M. Mogensen is a team leader dietitian specialist,
Brigham and Women’s Hospital, Boston, MA.
Address correspondence to: Kris M. Mogensen, MS, RD-AP, LDN, CNSC, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail:
kmogensen@bwh.harvard.edu
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
There is no funding to disclose.
ACKNOWLEDGEMENTS
Special acknowledgement and thanks to Stephanie Dobak, MS, RD, LDN, CNSC, and Ainsley Malone, MS, RDN, LD, CNSC, FAND, FASPEN, in
addition to Brett Baney, MS, RD; Kalli Castille, MS, RDN, LD, FAND; June Greaves, RD, CNSC, CD-N, LD, LDN, LRD; Carol Ireton-Jones, PhD, RDN, LD,
CNSC, FASPEN, FAND; Jessica Justice, RD, LDN, CNSC; Steven Plogsted, BS, PharmD, BCNSP, CNSC; Jennifer Sporay, MS, RDN-AP, CSO, LDN, CNSC,
FAND; Renee Walker, MS, RDN, LD, CNSC, FASPEN, FAND; and Hailey Wilson, MS, RD, CNSC, who willingly gave their time to review these
standards. The authors also give thanks to the Dietitians in Nutrition Support Dietetic Practice Group’s Executive Committee and the American
Society for Parenteral and Enteral Nutrition’s Clinical Practice Committee. The authors also extend thanks to all who were instrumental in the
process for the revisions of the article. Finally, the authors thank Academy staff, in particular, Carol Gilmore, MS, RDN, LD, FADA, FAND; Dana
Buelsing, MS, CAPM; Karen Hui, RDN, LDN; and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, who supported and facilitated the
development of these SOP and SOPPs.
AUTHOR CONTRIBUTIONS
Each author contributed to drafting and editing the components of the article (eg, article text and figures) and reviewed all drafts of the
manuscript.
FROM THE ACADEMY
Standards of Practice for Registered Dietitian Nutritionists in Nutrition Support

Standard 1: Nutrition Assessment
The registered dietitian nutritionist (RDN) uses accurate and relevant data and information to identify nutrition-related
problems.
Rationale:
Nutrition screening is the preliminary step to identify individuals who require a nutrition assessment performed by an RDN.
Nutrition assessment is a systematic process of obtaining and interpreting data in order to make decisions about the nature and
cause of nutrition-related problems and provides the foundation for nutrition diagnosis. It is an ongoing, dynamic process that
involves not only initial data collection, but also reassessment and analysis of patient/client or community needs. Nutrition
assessment is conducted using validated tools based in evidence, the 5 domains of nutrition assessment, and comparative
standards. Nutrition assessment may be performed via in-person, or facility/practitioner assessment application, or Health
Insurance Portability and Accountability Actecompliant video conferencing telehealth platform.
Indicators for Standard 1: Nutrition Assessment

Bold Font Indicators are Academy Core RDN Standards of Practice Indicators The “X” signifies the indicators
for the level of practice
Each RDN: Competent Proficient Expert
1.1 Patient/client/population history: Assesses current and past information X X X
related to personal, medical, family, and psychosocial/social history
1.1A Reviews admission nutrition screening data or screens for nutrition X X X
risk (eg, malnutrition, nutrient deficits, food security) using evidence-
based screening tools for the setting and/or population (adult or
pediatric)
1.1B Evaluates health status and disease conditions(s) history for X X X
application to nutrition care, including:
medical history, etiology of present conditions(s), and access
to health care
risk factors for medical conditions (eg, family medical history,
diabetes, hypertension, cardiovascular disease, chronic kidney
disease)
age-related nutrition issues and comorbidities (eg, diabetes,
obesity, hypertension, congestive heart failure, dyslipidemia,
depression, gastrointestinal diseases, ability to chew/swallow
foods and/or fluids)
evidence or documentation of malnutrition (eg, weight
change, abnormal rate of growth and weight gain, prolonged
poor intake, abnormal laboratory trends, previous physical
assessment findings)
history of tobacco use (eg, cigarettes, e-cigarettes, or
smokeless tobacco); and mental health, addiction, or sub-
stance use disorder
social determinants of health (eg, access to health care,
community resources; availability of housing and trans-
portation; social support; and economic stability)

Figure 1. Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Nutrition Support. Note: The terms patient, client,
customer, individual, person, group, or population are used interchangeably with the actual term used in a given situation depending
on the setting and the population receiving care or services.
October 2021 Volume 121 Number 10 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2086.e1
FROM THE ACADEMY

1.1C Assesses the effect of disease on ingestion, digestion, absorption, X X X
and utilization of nutrients, taking into consideration clinical factors
that may cause interference (mechanical, physiological, or
psychological); seeks assistance if needed
1.1D Evaluates psychosocial factors or issues; social and/or X X X
cognitive impairment support; depression/anxiety; and disordered
eating
1.1E Assesses history of mental health disorders (eg, depression, bipolar X X
disorder, anxiety, attention deficit hyperactivity disorder); seeks
assistance if needed
1.1F Assesses history of problems with ingestion, digestion, absorption, X X
and metabolism of macronutrients and micronutrients resulting
from comorbid conditions or complications (eg, diabetes, bariatric
surgery, end-stage kidney disease, swallowing disorders,
malnutrition)
1.1G Identifies potential nutrition complications related to chronic or X X
acute conditions
1.1H Distinguishes underlying potential for coexisting disease or nutrition X
conditions that may be contributing to present nutrition/disease
state
1.2 Anthropometric assessment: Assesses anthropometric indicators (eg, height, X X X
weight, body mass index, waist circumference, arm circumference),
comparison to reference data (eg, percentile ranks/z scores), and individual
patterns and history
1.2A Identifies age-appropriate reference standards for comparison X X X
1.2B Identifies and considers limitations of reference standards related to X X X
age, race, ethnicity, or gender
1.2C Estimates and modifies anthropometric measurements as X X X
appropriate (eg, for amputation(s), paralysis, physical or
developmental disabilities, or pregnancy)
1.2D Identifies and interprets trends in anthropometric indices taking into X X X
consideration cultural diversity (eg, for suboptimal growth and
development or overweight/obesity in children, adolescents, and
teens); seeks assistance if needed
1.2E Evaluates body composition using alternative anthropometric X X
assessment methods (eg, mid-arm muscle circumference, creatinine
height index)

Figure 1. (continued) Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Nutrition Support. Note: The terms patient,
client, customer, individual, person, group, or population are used interchangeably with the actual term used in a given situation
depending on the setting and the population receiving care or services.
2086.e2 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS October 2021 Volume 121 Number 10
FROM THE ACADEMY

1.2F Evaluates body composition using available diagnostic results (eg, X
magnetic resonance imaging scan, ultrasound, CTa scan or DEXAb)
1.3 Biochemical data, medical tests, and procedure assessment: Assesses X X X
laboratory profiles (eg, acidebase balance, renal function, endocrine
function, inflammatory response, vitamin/mineral profile, lipid profile), and
medical tests and procedures (eg, gastrointestinal study, metabolic rate)
1.3A Evaluates nutrition implications of diagnostic and therapeutic X X X
procedures:
laboratory data (eg, hyperglycemia, hyper/hypokalemia, dys-
lipidemia, and other nutrition-related biochemical
parameters)
blood pressure
Seeks assistance if needed

1.3B Assesses the need or potential benefit for additional diagnostic tests X X
(eg, abdominal imaging, modified barium swallow study,
malabsorption studies) or therapeutic procedures (eg, placement of
parenteral or enteral access device suitable for long-term nutrition
support therapy, ie, enteral nutrition [EN] or parenteral nutrition
[PN])
1.3C Evaluates appropriateness and validity of tests used to evaluate X X
nutrition status and/or effects of nutrition support therapy
1.3C1 Identifies physical/biochemical signs and symptoms of X X
nutrition supporterelated infections (eg, central line
infections) or other infections affecting the nutrition care
plan
1.3C2 Distinguishes between alterations in nutritional status that X X
may be a result of the disease process and treatment(s)
from those due to nutrient deficiencies; and intervenes
appropriately to address the underlying issue
1.3C3 Demonstrates understanding of complex invasive X
hemodynamic monitoring devices that may impact the
nutrition care plan (eg, pulmonary artery catheter)
1.3D Applies critical thinking and experience to interpret results of tests, X
procedures, and evaluations; and to identify additional data to
consider in assessment
1.4 Nutrition-focused physical examination (NFPE) may include visual and X X X
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)

FROM THE ACADEMY

1.4A Uses NFPE that includes, but is not limited to, oral and perioral X X X
structures; skin and related structures; alterations in taste, smell, and
dentition/chewing ability
1.4B Assesses for clinical signs and symptoms of malnutrition X X X
(undernutrition) (eg, wasting of fat or muscle; dry, brittle, or thinning
hair and nails; sarcopenia and cachexia; and decreased hand-grip
strength or other measures of physical functioning related to
nutrition)
1.4C Considers variations in physical presentation of illness and X X X
disease
1.4D Evaluates existing and potential access sites for delivery of EN or PN X X
therapy
1.4E Recognizes, evaluates, and communicates complications of PN and/ X X
or EN and/or associated access devices; alerts appropriate patient
care staff of findings in a timely manner
1.4F Performs, with documented competence, comprehensive NFPE, X
including abdominal and chest/lung examination when appropriate
1.5 Food and nutrition-related history assessment (ie, dietary assessment)
Evaluates the following components:
1.5A Food and nutrient intake including composition and adequacy, X X X
meal and snack patterns, and appropriateness related to food
allergies and intolerances
1.5A1 Assesses fluid intake, appetite, and dietary pattern X X X
changes (eg, oral issues, chewing and swallowing,
gastrointestinal problems, or comorbid conditions), and
any changes for potential impact on disease management
and indicators for nutrition support therapy
1.5A2 Assesses food and nutrient intake considering the X X X
following:
type and distribution of macronutrients and sources
of protein
adequacy of nutrient intake to maintain energy and
nitrogen balance
history of food allergies/intolerances (eg, gluten
sensitivity or intolerance, lactose intolerance)
understanding of dietary modifications super-
imposed with comorbidities (eg, diabetes, cardio-
vascular disease, infection, cancer)
cultural and/or religious food preferences
food access and/or presence of food insecurity

FROM THE ACADEMY

1.5A3 Assesses daily fluid needs for health, physical activity, X X X
fitness level, environmental conditions, and comorbid
conditions (eg, renal or heart failure)
1.5A4 Assesses adequacy of micronutrient and electrolyte X X X
(potassium, phosphorus, calcium, sodium) intake provided
enterally, comparing with evidence-based nutrition
recommendations for individuals across the lifespan
1.5A5 Assesses adequacy of micronutrient and electrolyte X X
(potassium, phosphorus, calcium, sodium) intake provided
parenterally, comparing with evidence-based nutrition
recommendations for individuals across the lifespan
1.5A6 Considers food allergies/intolerances in the provision of X X
PN (eg, allergens as it relates to intravenous fat emulsions
or other intravenous components)
1.5A7 Evaluates the implications for nutrition support therapy of X
reported food allergy(ies) and associated diseases or
conditions (eg, eosinophilic esophagitis) with EN or PN
components (eg, lipid emulsions)
1.5B Food and nutrient administration including current and previous X X X
diets and diet prescriptions and food modifications, eating
environment, and EN and PN administration
1.5B1 Calculates percent of estimated nutritional needs provided X X X
by previously documented oral, medical foods/nutrition
supplements, EN and/or PN intake
1.5B2 Consults with home infusion clinic/company or home care X X X
provider regarding oral, EN, PN, and/or hydration
prescription, when applicable
1.5B3 Recognizes over- and underfeeding nutrition situations X X X
and the associated complications
1.5B4 Considers need for EN/PN modifications to correct over- or X X X
underfeeding, such as EN infusion rate or PN
macronutrient content
1.5C Medication and dietary supplement use, including prescription X X X
and over-the-counter medications, and integrative and functional
medicine products
1.5C1 Assesses safety, quality, and efficacy of over-the-counter X X X
medications and integrative and functional medicine
products; evaluates actual or potential drugenutrient and
drugedrug interactions in consultation with pharmacist or
other professionals, if indicated, using database resources

FROM THE ACADEMY

(eg, Natural Medicines Database; https://naturalmedicines.
therapeuticresearch.com/); seeks assistance if needed
1.5C2 Assesses the nutrition implications of overall medication X X
regimen, including adherence, side effects, and
medication dose changes/discontinuation
1.5C3 Considers the need to add or discontinue medications that X
may alter nutrition status (eg, propofol, intravenous
electrolyte replacements)
1.5D Knowledge, beliefs, and attitudes (eg, understanding of nutrition- X X X
related concepts, emotions about food/nutrition/health, body
image, preoccupation with food and/or weight, readiness to
change nutrition- or health-related behaviors, and activities and
actions influencing achievement of nutrition-related goals)
1.5D1 Assesses patient/client perceptions of previous nutrition X X X
interventions
1.5D2 Considers patient’s/client’s/advocate’sc ability to X X X
understand the risks and benefits of food and beverage
choices and/or EN or PN when applicable considering
health conditions(s)
1.5D3 Evaluates: X X X
self-care skills, behaviors, health care knowledge/
beliefs/attitudes from the patient’s/client’s/
advocate’s/caregiver’s perspective
patient’s/client’s/advocate’s ability to identify
evidence-based nutrition information among
resources found in media and popular literature
various influences (eg, language, physical activity,
social networks, culture, ethnicity, and religion) that
may impact behavior change
1.5D4 Accounts for behavioral mediators (or antecedents) X X
related to nutrition support therapy (eg, attitudes,
knowledge, intentions, readiness, and willingness to
change; perceived social support; outside/caregiver
influence)
1.5D5 Reviews administration methods and use of equipment for X
nutrition support therapy, when applicable, in relation to
self-care skills, compliance, and behaviors
1.5E Food security defined as factors affecting access to a sufficient X X X
quantity of safe, healthful food and water, as well as food-/
nutrition-related supplies

FROM THE ACADEMY

1.5E1 Assesses food and water safety, access, and availability of X X X
healthy food/meals:
appropriate food preparation resources (eg, finan-
cial, food markets/grocery stores, and equipment
for safe cooking, serving, and food storage)
food environment or access (eg, use of food pantry,
meal programs, living situation, transportation)
plans for emergency situations/disaster events (eg,
availability of appropriate food, water, supply of
medications, nutrition supplements, or EN formula
and supplies when applicable)
availability of family/advocate/caregiver to assist
with obtaining/preparing food or home adminis-
tration of EN or PN, if needed
1.5E2 Evaluates ability to adhere to/participate in an appropriate X X
nutrition support therapy regimen
1.5E3 Evaluates the need for additional resources to overcome X X
barriers
1.5F Physical activity, cognitive and physical ability to engage in X X X
developmentally appropriate nutrition-related tasks (eg, self-
feeding and other activities of daily living [ADLs]), instrumental
ADLs (eg, shopping, food preparation), and breastfeeding
1.5F1 Assesses health literacy and numeracy (eg, ability to read, X X X
write, and perform calculations)
1.5F2 Identifies factors or events that may impact patient’s/ X X X
client’s physical and cognitive abilities (eg, hospitalization,
amputation, retinopathy, anemia, uremia/inadequate
dialysis, change in living situation or caregiver support)
1.5F3 Considers results from validated or commonly accepted X X
developmental, functional, and mental status
evaluation tools (eg, Karnofsky Performance Scale,
Pediatric Quality of Life inventory ADLs, frailty assessment
tools, depression screening tools) that reflect cultural,
ethnic, and lifestyle factors in collaboration with the
interprofessionald team
1.5F4 Considers changes in cognitive and/or physical X X
functioning that may affect ability to meet nutrition goals
1.5F5 Anticipates future changes in physical functioning that X
may affect ability to meet nutrition goals

FROM THE ACADEMY

1.5G Other factors affecting intake and nutrition and health status (eg, X X X
cultural, ethnic, religious, lifestyle influencers, psychosocial, and
social determinants of health)
1.5G1 Reviews/evaluates quality of life/end-of-life choices, X X X
including advanced directives and/or preferences relevant
to the nutrition plan of care
1.5G2 Assesses the risk/history of depression, anxiety, cognition X X
difficulties, disordered eating (eg, maladaptive practices
related to food intolerances), or substance abuse in
relation to current diagnosis(es) and comorbidities,
planned treatment, and the impact on nutritional status
1.5G3 Evaluates outcomes and quality of life parameters in X
patients/clients receiving nutrition support therapy
1.6 Comparative standards: Uses reference data and standards to estimate X X X
nutrient needs and recommended body weight, body mass index, and
desired growth patterns (eg, Academy EAL,e ASPEN,f NHANES,g KDOQIh)
1.6A Identifies the most appropriate reference data and/or standards X X X
(eg, international, national, state, institutional, and regulatory)
based on practice setting and patient-/client-specific factors (eg,
age, race, ethnicity, gender, or disease state)
1.6A1 Identifies nutrition support-related reference standards to X X
be included in organization’s/system’s assessment tools
1.6A2 Recognizes and takes the lead in incorporating guidelines X
from other practice areas (eg, diabetes, renal, pediatrics)
into assessment guidelines and practices for care setting
in collaboration with interprofessional team
1.6B Determines energy and nutrient requirements, using appropriate X X X
reference standards, considering the individual’s medical status,
food/EN and/or PN intake, level of activity, growth rate, growth
history, mobility, medications, and other factors affecting energy
requirements
1.6C Recognizes the effects of nutrition support therapy on the ingestion, X X
digestion, and absorption of nutrients
1.6D Evaluates implications of data, reference standards, and practice X
guidelines for impact on nutrition support therapy and
management
1.7 Physical activity habits and restrictions: Assesses physical activity, history of X X X
physical activity, and physical activity training

FROM THE ACADEMY

1.7A Compares usual activity level to current age-appropriate physical X X X
activity guidelines (https://health.gov/our-work/physical-activity/
current-guidelines)
1.7B Evaluates factors limiting physical activity (eg, visual disturbances, X X
mobility, medication contraindications, medical condition(s),
environmental safety)
1.7C Considers how current and/or proposed physical activity may alter X X
macronutrient requirements and fluid/hydration and revises
nutrition support regimen to account for activity levels
1.8 Collects data and reviews data collected and/or documented by the X X X
nutrition and dietetics technician, registered (NDTR), other health care
practitioner(s), patient/client, or staff for factors that affect nutrition and
health status
1.8A Communicates with the interprofessional team, patient/client, X X X
advocate or staff regarding collected data that requires additional
information and/or clarification before being used
1.8B Reviews and evaluates data to discern factors that may impact X X
nutrition support delivery
1.9 Uses collected data to identify possible problem areas for determining X X X
nutrition diagnoses
1.9A Evaluates and prioritizes nutrition-related problems (eg, intake, X X X
biochemical abnormalities, behavior change, weight change,
findings from NFPE or Subjective Global Assessment [SGA], physical
activity, medication(s), or treatment adherence) for factors that
influence health and nutrition status
1.9B Evaluates more complex issues related to food intake and/or EN or X X
PN therapy, and clinical complications (eg, presence of nutrition risk
factors or malnutrition and multiple complications) for prioritizing
nutrition diagnoses
1.9C Evaluates complex food-, medication-, or treatment-related issues, X
clinical complications, and current or anticipated treatment options
(eg, surgery, withdrawal of treatment, or other medical management
adjustments) in prioritizing nutrition problems in collaboration with
the interprofessional team
1.10 Documents and communicates:
1.10A Date and time of assessment X X X
1.10B Pertinent data (eg, medical, social, behavioral) X X X
1.10C Comparison to appropriate standards (eg, macronutrients, X X X
micronutrients)

FROM THE ACADEMY

1.10D Patient/client/population perceptions, values and motivation X X X
related to presenting problems
1.10E Changes in patient/client/population perceptions, values and X X X
motivation related to presenting problems
1.10F Reason for discharge/discontinuation or referral, if appropriate X X X
Examples of Outcomes for Standard 1: Nutrition Assessment

Appropriate assessment tools and procedures are used in valid and reliable ways
Appropriate and pertinent data are collected
Effective interviewing methods are used
Data are organized and in a meaningful framework that relates to nutrition problems
Use of assessment data leads to the determination that a nutrition diagnosis/problem does or does not exist
Problems that require consultation with or referral to another provider are recognized
Documentation and communication of assessment are complete, relevant, accurate, and timely
Standard 2: Nutrition Diagnosis

The registered dietitian nutritionist (RDN) identifies and labels specific nutrition problem(s)/diagnosis(es) that the RDN is
responsible for treating.
Rationale:
Analysis of the assessment data leads to identification of nutrition problems and a nutrition diagnosis(es), if present. The
nutrition diagnosis(es) is the basis for determining outcome goals, selecting appropriate interventions, and monitoring progress.
Diagnosing nutrition problems is the responsibility of the RDN.
Indicators for Standard 2: Nutrition Diagnosis

2.1 Diagnoses nutrition problems based on evaluation of assessment data and X X X
identifies supporting concepts (ie, etiology, signs, and symptoms)
2.1A Organizes and groups data consisting of physical, clinical, psychosocial, X X X
behavioral-environmental, and nutrition assessment findings to
determine nutrition diagnosis(es) (eg, significant and adequate
information for drawing conclusions)
2.1B Evaluates findings systematically using critical thinking and experience X X X
with the population and nutrition support therapy when formulating
the nutrition diagnosis; consults with interprofessional team or more
experienced practitioner as needed

FROM THE ACADEMY

2.1C Identifies, organizes, and prioritizes comprehensive nutrition problem X X
list considering the following:
current diagnosis(es) and medical/surgical history and outcomes
to identify etiology(ies)
signs and symptoms obtained through NFPE
nutrition intake data (food, nutrition supplements, EN and/or
PN), clinical condition, and comorbidities (eg, diabetes, chronic
kidney disease, chewing/swallowing disorder) or interventions
(eg, bariatric surgery)
2.1D Investigates and identifies new etiologies for the nutrition problem(s) X X
based on signs and symptoms
2.1E Systematically compares and contrasts assessment findings in X X
formulating a differential nutrition diagnosis(es)
2.1F Anticipates the multifaceted effects of disease progression on the X
proposed nutrition diagnosis(es)
2.1G Identifies and recognizes physical/biochemical signs and symptoms of X
nutrition supporterelated infections (eg, central line infection) or other
infections affecting the nutrition diagnosis(es)
2.2 Prioritizes the nutrition problem(s)/diagnosis(es) based on severity, safety, X X X
patient/client needs and preferences, ethical considerations, likelihood that
nutrition intervention/plan of care will influence the problem, discharge/
transitions of care needs, and patient/client/advocate perception of importance
2.2A Prioritizes nutrition diagnosis(es) in order of importance or urgency X X X
using evidence-based protocols and guidelines for nutrition support
2.2B Evaluates assessment data to prioritize nutrition problems/ X X X
diagnosis(es) considering:
impact/urgency of the identified problems (eg, risk for refeeding
syndrome; persistent inadequate energy or protein intake)
complications of comorbid diseases or conditions (eg, diabetes,
hypertension, nonhealing wound or pressure injury)
patient/client/advocate wishes and perceptions of importance
including palliative care
life-cycle stage
evidence-based protocols and guidelines
2.2C Recognizes nutrition support-related problems in the context of X X

patient/client-centered care, optimizing nutrition support therapy to
obtain positive outcomes

FROM THE ACADEMY

2.2D Works/collaborates with interprofessional team to: X X
verify medical/surgical diagnosis(es) and nutrition diagnosis(es)
and to determine priority order of nutrition diagnosis(es)
determine goals of care and indications for nutrition support ther-
apy, including utility of implementing or continuing EN or PN at the
end of life; seeks assistance from more experienced RDN if needed
2.2E Guides interprofessional team discussions to address nutrition needs X
and plans of care for patients/clients with multiple complex care and/or
transition of care issues to achieve positive outcomes
2.3 Communicates the nutrition diagnosis(es) to patients/clients/advocates, X X X
community, family members, or other health care professionals when
possible and appropriate
2.3A Communicates and confirms the nutrition diagnosis(es) using clinical X X X
judgment skills (eg, addresses urgent/critical problem(s), reflects wishes
of patient/client/advocate, consistent with medical/treatment care plan)
2.3B Educates the interprofessional team on the specific nutrition X X
diagnosis(es) (eg, malnutrition)
2.4 Documents the nutrition diagnosis(es) using standardized terminology and X X X
clear, concise written statement(s) (eg, using Problem [P], Etiology [E], and
Signs and Symptoms [S] [PES statement(s)] or Assessment [A], Diagnosis [D],
Intervention [I], Monitoring [M], and Evaluation [E] [ADIME statement(s)])
2.4A Documents and explains nutrition diagnosis(es) in order of importance X X X
and in a manner that clearly describes the patient’s/client’s nutrition
status and needs
2.4B Explains relationship of nutrition diagnosis(es) to need/rationale for X X
nutrition support therapy in communications and documentation
2.4C Anticipates and documents projected modifications of nutrition X
support therapy based on nutrition diagnosis(es) and/or clinical
changes for patients/clients currently receiving EN or PN
2.5 Re-evaluates and revises nutrition diagnosis(es) when additional assessment X X X
data become available
2.5A Uses most current information that may impact nutrition diagnosis(s), X X X
revises if needed, and communicates change to interprofessional team,
patient/client/advocate/caregiver as appropriate in a timely manner
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

FROM THE ACADEMY
Standard 3: Nutrition Intervention/Plan of Care

The registered dietitian nutritionist (RDN) identifies and implements appropriate, person-centered interventions designed to
address nutrition-related problems, behaviors, risk factors, environmental conditions, or aspects of health status for an
individual, target group, or the community at large.
Rationale:
Nutrition intervention consists of 2 interrelated components—planning and implementation.
Planning involves prioritizing the nutrition diagnoses, conferring with the patient/client and others, reviewing practice
guidelines, protocols and policies, setting goals, and defining the specific nutrition intervention strategy.
Implementation is the action phase that includes carrying out and communicating the intervention/plan of care,
continuing data collection, and revising the nutrition intervention/plan of care strategy, as warranted, based on change in
condition and/or the patient/client/population response.
An RDN implements the interventions or assigns components of the nutrition intervention/plan of care to professional,
technical, and support staff in accordance with knowledge/skills/judgment, applicable laws and regulations, and organization
policies. The RDN collaborates with or refers to other health care professionals and resources. The nutrition intervention/plan of
care is ultimately the responsibility of the RDN.
Indicators for Standard 3: Nutrition Intervention/Plan of Care

Plans the Nutrition Intervention/Plan of Care:
3.1 Addresses the nutrition diagnosis(es) by determining and prioritizing X X X
appropriate interventions for the plan of care
Prioritization considerations may include:
3.1A Severity of nutrition risk or malnutrition X X X
3.1B Presence of comorbid diseases/conditions X X X
3.1C Patient’s/client’s/advocate’s ability and willingness to implement X X X
and adhere to nutrition care plan
3.1D Actual or risk of acute complications X X
3.1E Anticipation of delayed/late effects of therapy (eg, metabolic X X
abnormalities, catheter infection)
3.1F Analysis of risk/benefits of initiating nutrition support therapy for X X
patient nearing end of life
3.2 Bases intervention/plan of care on best available research/evidence and X X X
information, evidence-based guidelines (eg, Academy EAL, ASPEN), and
best practices (see Figure 4 for resources)
3.2A Applies critical thinking skills reflecting nutrition support knowledge X X
and experience to develop an intervention plan, using current
evidence-based practice guidelines to individualize patient/client
care

FROM THE ACADEMY

3.2B Recognizes when it is appropriate and safe to recommend deviation X X
from established nutrition guidelines and protocols in consultation
with interprofessional team when indicated
3.2C Synthesizes multiple evidence-based guidelines to develop an X
intervention plan for patient/client with multiple medical problems (eg,
critical illness combined with obesity, diabetes, and acute kidney injury)
3.3 Refers to policies and procedures, protocols, and program standards X X X
3.4 Collaborates with patient/client/advocate/population, caregivers, X X X
interprofessional team, and other health care professionals
3.4A Serves as an integral member of the interprofessional team X X X
3.4A1 Recognizes specific knowledge and skills of the patient/ X X X
client and of other providers in developing the plan of care
3.4A2 Serves as a resource to colleagues and the X X
interprofessional team on medical nutrition therapy and
developing and managing the nutrition support therapy
care plan
3.4A3 Leads the collaborative process with interprofessional X
team members and other providers, when applicable, in
developing the nutrition support therapy care plan
3.4A4 Teaches clinical practice skills and rationales for nutrition X
interventions to students, colleagues, and
interprofessional team members
3.4B Evaluates pertinent data (eg, results of abdominal x-rays, access X X
device placement [eg, intravenous catheters or feeding tubes]), and
collaborates with other interprofessional team members to develop
the nutrition support therapy care plan
3.4C Recommends and, in consultation with pharmacist, suggests X X
alternative methods, as applicable to the situation, to minimize drug
enutrient interactions related to nutrition support therapy
3.5 Works with patient/client/advocate/population and caregivers to identify X X X
goals, preferences, discharge/transitions of care needs, plan of care, and
expected outcomes
3.5A Develops clear and measurable goals, outcomes, and plan(s) with X X X
patient/client/advocate through shared decision making and
consideration of readiness to change and barriers to successful
implementation
3.5B Explains to patient/client/advocate the risks and benefits of the X X X
recommended nutrition support therapy; obtains guidance from
more experienced practitioner, if needed

FROM THE ACADEMY

3.5C Develops nutrition support care plan and disseminates to patient/ X X
client/advocate and/or other health care team members as
appropriate
3.6 Develops the nutrition prescription and establishes measurable patient-/ X X X
client-focused goals to be accomplished
3.6A Develops or revises the nutrition prescription based on nutrition X X X
assessment or re-assessment and nutrition diagnosis(es), treatment
plan, goals, and expected outcomes
3.6A1 Considers the educational needs of the patient/client/ X X X
advocate or caregiver, taking into account cultural
competency, health literacy, food access, and preparation
skills, if applicable to achieve person-centered goals
3.6A2 Selects nutrition support modalities (ie, oral, EN and/or PN) X X X
to meet patient’s/client’s macro- and micronutrient
requirements
3.6A3 Determines fluid requirements and appropriate volume of X X X
EN/PN formulation
3.6A4 Determines macronutrient content of EN/PN formulation X X X
Protein
Carbohydrate
Fat
3.6A5 Determines micronutrient content of EN/PN formulation X X

Vitamins
Minerals
Electrolytes
Trace elements
3.6A6 Determines micronutrient supplementation required in X

addition to micronutrients provided via EN/PN formulation
3.6B Anticipates potential complications of nutrition intervention (eg, X X
altered glycemic control, electrolyte abnormalities)
3.6C Plans for transition to alternate mode of nutrition support therapy X X
and/or oral diet, as appropriate
3.6D Reviews and determines need for initiation and/or adjustment of X X
pharmacotherapy, considering nutrition, physical activity, growth,
medication, blood glucose and other laboratory data, and physical
examination (eg, intensification of medication management
[adjusting dose/timing], discontinuation of medications based on
progression of the disease or macronutrient impact), as part of an
interprofessional team
3.7 Defines time and frequency of care including intensity, duration, and follow-up X X X

FROM THE ACADEMY

3.7A Determines duration and follow-up of care using evidence-based X X X
guidelines (eg, EAL, ASPEN), standards of care, facility policy, patient/
client needs, established goals and outcomes, and expected
response to intervention(s)
3.7B Determines appropriate follow-up based on anticipated tolerance of X X X
EN/PN prescription or oral diet adequacy, current condition, and
potential changes in care plan (eg, swallow study ordered, or
surgery scheduled); seeks assistance if needed
3.7C Provides or develops guidelines reflecting practice guidelines, X X
organization standards, regulations to orient new and/or entry-level
staff (eg, RDNs, nurses, interprofessional team)
3.7D Creates and documents contingency planning based on potential X
responses to nutrition support therapy
3.8 Uses standardized terminology for describing interventions X X X
3.9 Identifies resources and referrals needed X X X
3.9A Identifies age-appropriate resources and tools to assist patient/ X X X
client/advocate with management of nutrition support therapy (eg,
mobile apps, community and/or web-based support groups)
3.9B Identifies and facilitates referrals to programs and/or providers (eg, X X X
social work, gastroenterology, surgeon, physical therapist, speech
language pathologist, mental health professional) to assist patient/
client/advocate with nutrition support-related issues (eg, financial
assistance, in home support services)
3.9C Coordinates with social work or case management and home X X
infusion nutrition support practitioner to develop transitions of care
plan for patient/client who will discharge on home nutrition support
(new or continuing on home nutrition support) (eg, insurance
coverage, referral to home infusion program, caregiver training,
additional resources)
Implements the Nutrition Intervention/Plan of Care:
3.10 Collaborates with colleagues, interprofessional team, and other health care X X X
professionals
3.10A Collaborates with the medical and/or surgical team to facilitate the X X X
nutrition support care plan
3.10A1 Offers alternatives and potential solutions to nutrition- X X
related problems
3.10B Communicates any revision of the nutrition support care plan with X X X
the interprofessional team

FROM THE ACADEMY

3.10C Reviews ongoing and new data (eg, results of abdominal x-rays, X X
access device placement [eg, intravenous catheter and feeding
tube]) and collaborates with other interprofessional team members
to revise and implement the nutrition support therapy plan
3.10D Facilitates and fosters active communication, learning, partnerships, and X X
collaboration with interprofessional team and others as appropriate
3.10E Leads or directs the interprofessional team and others consistent X
with role and responsibilities
3.11 Communicates and coordinates the nutrition intervention/plan of care X X X
3.11A Ensures that patient/client and, as appropriate, family/advocate/ X X X
caregiver, understand and can articulate goals and other aspects of
the plan of care
3.11B Coordinates the nutrition support therapy intervention with the X X
interprofessional team (eg, confers with peripherally inserted central
catheter team regarding central venous access before PN initiation)
3.11C Collaborates with interprofessional team or other health care X
provider(s) to facilitate coordination of care and awareness of
potentially conflicting/problematic treatments (eg, medication-
dietary supplement interactions)
3.12 Initiates the nutrition intervention/plan of care X X X
3.12A Uses approved clinical privileges, physician/non-physician X X X
practitioneri-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
3.12A1 Implements, initiates, or modifies orders for X X X
therapeutic diet, nutrition-related pharmacotherapy
management, or nutrition-related services (eg, medical
foods/nutrition/dietary supplements, food texture
modifications, EN and PN, laboratory tests,
medications, and education and counseling)
3.12A1i Orders or recommends: X X X
diet order modification to correct
over and under macro- and/or
micronutrient levels or patient re-
ported food intolerances or allergies
menu modifications to address
insufficient intake or preferences
oral nutrition supplementation
changes to EN feeding rate and/or
supplemental water, when applicable

FROM THE ACADEMY

3.12A1ii Places initial or revised orders for EN X X X
regimens (eg, formula, volume per feeding
or per day, initial and goal rate and
advancement schedule, supplemental
water; and modular products [eg, protein,
fiber]) when applicable
3.12A1iii Places initial or revised orders for premixed X X
or compounded PN regimens—peripheral
or central line administration (eg, amino
acid solution, lipid solution, supplemental
vitamins, and trace elements, if indicated) in
consultation with pharmacist as needed
3.12A1iv Uses results of studies (eg, CT scan, swallow X X
evaluation) or recommends or, with clinical
privileges, orders laboratory tests and other
procedures to support evaluation and
monitoring of the nutrition support therapy
regimen(s), including but not limited to:
indirect calorimetry
bioelectric impedance analysis
vitamin/mineral levels
3.12A1v Collaborates with the clinical pharmacist to X X

determine alternative products (eg,
electrolytes, amino acids, lipids, vitamins,
minerals, trace elements) and routes (eg,
converting intravenous to enteral types)
during periods of product shortages
3.12A1vi Places initial or revised orders for fluid X
therapies or electrolyte replacements
3.12A1vii Recommends in consultation with the X
interprofessional team, insertion and
placement verification of PN access devices
3.12A2 Manages nutrition support therapies (eg, formula X X X
selection, rate adjustments, addition of designated
medications and vitamin/mineral supplements to PN
solutions or supplemental water for enteral nutrition)
3.12A2i Reviews patient/client care plan with the X X X
interprofessional team at regular intervals
to provide safe, effective, and evidence-
based nutrition support therapy

FROM THE ACADEMY

3.12A2ii Generates appropriate nutrition support X X
therapy care plans with the
interprofessional team to meet unique
needs of patients/clients with complex,
chronic conditions
3.12A2iii Recommends, or with clinical privileges, X X
orders laboratory tests and other
monitoring methods necessary for
evaluating and adjusting the nutrition
support regimen as indicated, including but
not limited to:
indirect calorimetry
bioelectrical impedance analysis
vitamin/mineral levels
3.12A2iv Leads the interprofessional team through X

an analytical decision-making process in
complicated, unpredictable, and dynamic
situations
3.12A3 Initiates and performs nutrition-related services (eg, X X X
bedside swallow screenings, monitoring positioning of
nasoenteric feeding tubes, and indirect calorimetry
measurements, or other permitted services)
3.12A3i Oversees nutrition staff trained to perform X X
indirect calorimetry measurements when
applicable, and interprets results in
collaboration with the respiratory therapist
3.12A3ii Inserts nasogastric or nasoenteric feeding X
tubes and/or obtains order for swallow
study consistent with specialized training
and clinical privileges/delegated orders
3.12A3iii Uses ultrasound to assess body X
composition consistent with specialized
training and clinical privileges/delegated
orders
3.12B Identifies tools for nutrition education to support the intervention/ X X X
plan of care that are appropriate to the patient’s/client’s and/or
advocate’s/caregiver’s educational needs, learning style, and
method of communication; uses interpersonal teaching, training,
coaching, counseling, or technological approaches, as appropriate

FROM THE ACADEMY

3.12C Tailors nutrition intervention to the developmental stage and X X
cognitive functioning of the patient/client and makes changes to
the intervention as appropriate
3.12D Draws on experiential and evidence-based knowledge about the X
patient/client population to individualize the strategy for complex
and dynamic interventions (eg, complex comorbidities, medical or
psychological instability)
3.13 Assigns activities to NDTR and other professional, technical and support X X X
personnel in accordance with qualifications, organizational policies/
protocols, and applicable laws and regulations
3.13A Supervises professional, technical and support personnel (eg, X X X
direct nutrition-related care provided to patients/clients; in the
collection of laboratory data, intake/output records, and intake
analysis)
3.13B Trains qualified support personnel (eg, obtaining data from intake X X
and output forms, completing intake analysis incorporating oral, EN
and/or PN as applicable to patient/client)
3.13C Develops nutrition supporterelated training modules and X
evaluation tools for personnel to aid in the effective completion of
designated activities
3.14 Continues data collection X X X
3.14A Analyzes data trends to modify plans, if indicated; consults with X X X
more experienced practitioner or interprofessional team as needed
3.14B Responds to clinical data analysis by recommending or ordering X X
relevant tests, and/or adjusting the frequency of existing test orders
consistent with clinical privileges/delegated orders
3.14C Analyzes data trends to predict future deviations in the nutrition X
support plan, develops plan modifications as indicated, and
communicates to the interprofessional team as needed
3.15 Documents:
3.15A Date and time X X X
3.15B Specific and measurable treatment goals and expected outcomes X X X
3.15C Recommended interventions X X X
3.15D Patient/client/advocate/caregiver/community receptiveness X X X
3.15E Referrals made and resources used X X X
3.15F Patient/client/advocate/caregiver/community comprehension X X X
3.15G Barriers to change X X X

FROM THE ACADEMY

3.15H Other information relevant to providing care and monitoring X X X
progress over time
3.15I Plans for follow-up and frequency of care X X X
3.15J Rationale for discharge or referral if applicable X X X
Examples of Outcomes for Standard 3: Nutrition Intervention/Plan of Care

Goals and expected outcomes are appropriate and prioritized
Patient/client/advocate/population, caregivers, and interprofessional teams collaborate and are involved in developing
nutrition intervention/plan of care
Appropriate individualized patient-/client-centered nutrition intervention/plan of care, including nutrition prescription, is developed
Nutrition intervention/plan of care is delivered, and actions are carried out as intended
Discharge planning/transitions of care needs are identified and addressed
Documentation of nutrition intervention/plan of care is:
B Specific
B Measurable
B Attainable
B Relevant
B Timely
B Comprehensive
B Accurate
B Dated and Timed
Standard 4: Nutrition Monitoring and Evaluation

The registered dietitian nutritionist (RDN) monitors and evaluates indicators and outcomes data directly related to the nutrition
diagnosis, goals, preferences, and intervention strategies to determine the progress made in achieving desired results of
nutrition care and whether planned interventions should be continued or revised.
Rationale:
Nutrition monitoring and evaluation are essential components of an outcomes management system in order to assure quality,
patient-/client-/population-centered care and to promote uniformity within the profession in evaluating the efficacy of nutrition
interventions. Through monitoring and evaluation, the RDN identifies important measures of change or patient/client/
population outcomes relevant to the nutrition diagnosis and nutrition intervention/plan of care; describes how best to measure
these outcomes; and intervenes when intervention/plan of care requires revision.
Indicators for Standard 4: Nutrition Monitoring and Evaluation

4.1 Monitors progress:
4.1A Assesses patient/client/advocate/population understanding and X X X
compliance with nutrition intervention/plan of care

FROM THE ACADEMY

4.1A1 Collaborates with the interprofessional team to ensure X X X
patient/client/advocate understanding of the nutrition
support therapy prescription
4.1A2 Determines whether barriers to understanding are present X X X
and impacting the patient’s/client’s/advocate’s/caregiver’s
compliance with the nutrition intervention/plan of care;
seeks assistance if needed
4.1A3 Reassess patient’s/client’s stage of behavior change and X X X
learning style to evaluate need to revise nutrition
intervention and plan of care
4.1A4 Evaluates patient’s/client’s ability to adhere to the plan of X X
care during hospitalization and after discharge
4.1A5 Refers patient/client to other providers (eg, social work, X X
mental health) and/or community resources as indicated
based on assessment to improve adherence to the plan of
care
4.1B Determines whether the nutrition intervention/plan of care is being X X X
implemented as prescribed
4.1B1 Identifies barriers to implementation of the plan of care X X X
when applicable
4.1B2 Verifies that volume or goal rate of EN or composition and X X X
rate of PN formula matches the order/prescription
4.1B3 Communicates and collaborates with members of the X X X
interprofessional team and/or others to verify progress and
share observations and concerns such as:
barriers to implementation of plan of care
unable to reach goal rate (eg, diarrhea, fluid limits)
4.1B4 Identifies and pursues strategies to overcome known X X

barriers
4.1B5 Evaluates nutrition intervention progress in the face of X
complex clinical situations (eg, multiple comorbid conditions,
post-bariatric surgery, malnutrition inflammatory syndrome,
multiple organ failure, transplant)
4.2 Measures outcomes:
4.2A Selects the standardized nutrition care measurable outcome X X X
indicator(s)

FROM THE ACADEMY

4.2A1 Considers patient/client-centered outcomes (eg, quality of X X X
life, physical well-being, anthropometric and laboratory data,
and individual’s/advocate’s satisfaction)
4.2A2 Uses multiple data sources to assess progress X X X
Examples include:
adequacy of food and nutrition supplements, when
applicable
volume and adequacy of EN and/or PN formula, when
applicable
changes in body weight, composition
laboratory and other test results
positive/negative effects of pertinent medications and
dietary supplements
changes in cognitive and functional status
changes in skin integrity
change in physical activity level
Seeks assistance if needed

4.2A3 Identifies individualized outcomes according to X X
comprehensive review of clinical status
4.2B Identifies positive or negative outcomes including impact on X X X
potential needs for discharge/transitions of care
4.2B1 Documents progress in meeting desired goals (eg, weight X X X
gain or maintenance, improved meal/snack/nutrition
supplement intake or tolerance of EN formula, progress
toward weaning from EN and/or PN to food, when
applicable)
4.2B2 Identifies unintended consequences (eg, continued weight X X
loss, blood glucose variability), or the use of inappropriate
methods of achieving goals (eg, medication or dietary
supplement erratic use/noncompliance, self-imposed dietary
restrictions, personal beliefs)
4.2B3 Uses knowledge of the population, experience, and critical X
thinking in evaluating complex changes in condition(s),
impact of interventions, and other factors on achievement of
outcomes
4.3 Evaluates outcomes:
4.3A Compares monitoring data with nutrition prescription and X X X
established goals or reference standard

FROM THE ACADEMY

4.3A1 Completes analysis of the indicators for each problem area X X
using additional monitoring tools, such as:
functionality/ADLs
respiratory weaning parameters
indirect calorimetry measurement and interpretation
detailed radiology examinations
serial and trended laboratory test results
4.3A2 Evaluates impact of patient’s/client’s right to self- X X

determination and its effect on the planned interventions
and achieving desired health outcomes and/or quality of life
in consultation with the interprofessional team
4.3A3 Analyzes the data considering the complexity of problems X
and correlates one problem to another (eg, using expert
clinical judgment skills in the presence of often multiple
complex comorbidities)
4.3A4 Benchmarks individual patient/client data to national, X
regional, and local data sets (eg, Oley Foundation, National
Nosocomial Infection Surveillance System; other applicable
reference standards or benchmarking systems)
4.3B Evaluates impact of the sum of all interventions on overall patient/ X X X
client/population health outcomes and goals
4.3B1 Evaluates the patient’s/client’s variance from planned X X X
outcomes and incorporates findings into future
individualized treatment recommendations
4.3B2 Assesses need for continuation of interventions based on X X
outcomes and clinical data (eg, weight now within normal
limits, patient/client alert and desires change to oral diet)
4.3B3 Determines cost-to-benefit ratio of current evidence-based X
interventions/best practices and outcomes when evaluating
need for change in patient’s/client’s nutrition support plan
4.3B4 Completes a trending analysis of the indicators and how they X
correlated with each other to identify patterns, to determine
and evaluate the complexity of problems, and influence on
patient/client/population health outcomes in collaboration
with the interprofessional team
4.3C Evaluates progress or reasons for lack of progress related to X X X
problems and interventions

FROM THE ACADEMY

4.3C1 Reviews collected data (eg, NFPE [initial or reassessment], X X
laboratory and diagnostic test results, food/nutrition
supplement and/or EN or PN intake, and procedure results
[eg, swallow studies, abdominal radiographs] to evaluate
therapy outcomes and/or to identify any unanticipated
finding[s])
4.3C2 Recognizes problems that are beyond the scope of nutrition X X
that are interfering with interventions and achieving desired
outcomes; makes referrals or consults with interprofessional
team to address issues
4.3D Evaluates evidence that the nutrition intervention/plan of care is X X X
maintaining or influencing a desirable change in the patient/client/
population behavior or status
4.3D1 Evaluates factors (physical, social, cognitive, environmental) X X X
that may influence response to nutrition intervention and
consults with interprofessional team as needed
4.3D2 Incorporates patient/client-specific evidence from multiple X X
areas (eg, anthropometrics, signs and symptoms of nutrient
deficiencies, biochemical data, medication use) to determine
the status of established goals and outcomes
4.3D3 Initiates interprofessional team or referring practitioner X X
consultation to identify next steps for interventions when
indicated for unstable and rapidly changing patient/client
status
4.3D4 Analyzes outcome measures to assess overall effectiveness of X
nutrition intervention/plan of care
4.3E Supports conclusions with evidence X X X
4.3E1 Uses evidence-based standards to evaluate patient/client X X X
outcomes (eg, Academy EAL guidelines and/or the Society of
Critical Care Medicine/ASPEN Critical Care Guidelines)
4.4 Adjusts nutrition intervention/plan of care strategies, if needed, in X X X
collaboration with patient/client/population/advocate/caregiver and
4.4A Improves or adjusts intervention/plan of care strategies based upon X X X
outcomes data, trends, best practices, and comparative standards
4.4A1 Modifies intervention strategies as needed (eg, change in X X X
health status, transition from EN to oral diet, change in
patient/client/advocate preferences or transition to hospice
care); seeks assistance if needed

FROM THE ACADEMY

4.4A2 Modifies nutrition support therapy as appropriate to address X X
patient/client needs, new/emerging situation (such as
comorbidities and complications), and results of any further
testing
4.4A2i Troubleshoots connection(s) issues and X X
collaborates with interprofessional team members
to assure appropriate access
4.4A2ii Identifies supply issues that hinder safe and timely X X
delivery of nutrition support and intervenes to
identify alternative solutions (eg, during vitamin
shortages)
4.4A3 Integrates interprofessional team input and refines X X
prescribed nutrition intervention/plan of care
4.4A4 Anticipates and solves future barriers to delivery of the plan X
and adjusts nutrition support care plan, as indicated
4.4B Implements the revised nutrition care plan consistent with best X X X
practices and impact on patient/client care
4.4C Ensures communication of nutrition plan of care and transfer of X X X
nutrition-related data between care settings (eg, acute care, home
health, ambulatory care, and/or long-term care facility) as needed
4.4D Arranges for additional resources and support services (eg, training of X X
direct care providers, collaboration with health care professionals for
implementing nutrition intervention/plan of care in patients/clients
balancing multiple situations [eg, emergency situations, and/or clinical
complications])
4.4E Tailors tools and methods to ensure desired outcomes reflect the X X
patient’s/client’s developmental age, social, physical, environmental
factors, and nutrition support treatment goals
4.4F Adjusts in complicated situations by drawing on practice experience, X
knowledge, clinical judgment, and evidence-based practice about the
patient/client population in complicated, unpredictable, and dynamic
situations (eg, critical care, eating disorders, wound management, and
factors related to comorbid conditions/complications)
4.5 Documents:
4.5A Date and time X X X
4.5B Indicators measured, results, and the method for obtaining X X X
measurement
4.5C Criteria to which the indicator is compared (eg, nutrition X X X
prescription/goal or a reference standard)

FROM THE ACADEMY

4.5D Factors facilitating or hampering progress X X X
4.5E Other positive or negative outcomes X X X
4.5F Adjustments to the nutrition intervention/plan of care, if indicated X X X
4.5G Future plans for nutrition care, nutrition monitoring and evaluation, X X X
follow-up, referral, or discharge
Examples of Outcomes for Standard 4: Nutrition Monitoring and Evaluation

The patient/client/community outcome(s) directly relate to the nutrition diagnosis and the goals established in the
nutrition intervention/plan of care. Examples include, but are not limited to:
B Nutrition outcomes (eg, change in knowledge, behavior, food, or nutrient intake)
B 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)
B Patient/client/population-centered outcomes (eg, quality of life, satisfaction, self-efficacy, self-management,
functional ability)
B Health care utilization and cost effectiveness outcomes (eg, change in medication, special procedures, planned/
unplanned clinic visits, preventable hospital admissions, length of hospitalizations, prevented or delayed nursing
home admissions, morbidity, and mortality)
Nutrition intervention/plan of care and documentation is revised, if indicated
Documentation of nutrition monitoring and evaluation is:
B Specific
B Measurable
B Attainable
B Relevant
B Timely
B Comprehensive
B Accurate
B Dated and Timed
a
CT ¼ computed tomography.
b
DEXA ¼ dual-energy x-ray absorptiometry.
c
Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the
patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the
patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the
patient/client has lost decision-making capacity. (Adapted from definitions within The Joint Commission Glossary of Terms13
and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation.7)
d
Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group
of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, psychologists, social workers, speech language
pathologists, and occupational and physical therapists), depending on the needs of the patient/client. Interprofessional could
also mean interdisciplinary or multidisciplinary.
e
Academy EAL ¼ Academy of Nutrition and Dietetics Evidence Analysis Library (www.andeal.org).
FROM THE ACADEMY
f
ASPEN ¼ American Society for Parenteral and Enteral Nutrition (www.nutritioncare.org).
g
NHANES ¼ National Health and Nutrition Examination Survey (www.cdc.gov/nchs/nhanes/about_nhanes.htm).
h
KDOQI ¼ Kidney Disease Outcomes Quality Initiative (www.andeal.org/topic.cfm?menu¼5303&cat¼5557).
i
Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse
specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist,
anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a
facility’s governing body and medical staff must be in accordance with state law.7,8 The term privileging is not referenced in the
Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the
Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities,
may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition
supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if
consistent with state law and organization policies.10,11
FROM THE ACADEMY
Standards of Professional Performance for Registered Dietitian Nutritionists in Nutrition Support

Standard 1: Quality in Practice
The registered dietitian nutritionist (RDN) provides quality services using a systematic process with identified ethics, leadership,
accountability, and dedicated resources.
Rationale:
Quality practice in nutrition and dietetics is built on a solid foundation of education and supervised practice, credentialing,
evidence-based practice, demonstrated competence, and adherence to established professional standards. Quality practice
requires systematic measurement of outcomes, regular performance evaluations, and continuous improvement.
Indicators for Standard 1: Quality in Practice

Bold Font Indicators are Academy Core RDN Standards of Professional The “X” signifies the indicators
Performance Indicators for the level of practice
1.1 Complies with applicable laws and regulations as related to their area(s) of X X X
practice
1.1A Complies with state licensure or certification laws and federal or X X X
state regulations, if applicable, including telehealth and continuing
education requirements
1.2 Performs within individual and statutory scope of practice and applicable X X X
laws and regulations
1.2A Understands and works within individual scope of practice in X X X
nutrition support; assures:
job description/contract specifications comply with defined
scope of practice, employer requirements, identified role, and
professional responsibility
consistency with credentialing requirements (eg, Certified
Nutrition Support Clinician [CNSC], Advanced Practitioner
Certification in Clinical Nutrition [RDN-AP], Board Certified
Specialist in Renal Nutrition [CSR] and/or Pediatric Critical Care
Nutrition [CSPCC])
1.3 Adheres to sound business and ethical billing practices applicable to the X X X
role and setting
1.3A Develops understanding of the payment and reimbursement X X X
environments for hospitals, long-term care facilities, and home
delivery of enteral nutrition (EN) or parenteral nutrition (PN) support
(eg, Medicare, Medicaid, private payors)
1.3B Operates within ethical reporting of nutrition support services X X X
provided
1.4 Uses national quality and safety data (eg, National Academies of Sciences, X X X
Engineering, and Medicine: Health and Medicine Division, National Quality
Forum, Institute for Healthcare Improvement, ASPEN,a Academyb) to
improve the quality of services provided and to enhance customer-centered
services (eg, nutrition support practice)

Figure 2. Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Nutrition Support. Note: The term
customer is used in this evaluation resource as a universal term. Customer could also mean client/patient/customer, family,
participant, consumer, or any individual, group, or organization to which the RDN provides service.
FROM THE ACADEMY

1.4A Reviews existing national quality and safety recommendations and X X X
applies to nutrition support practice
1.4B Translates safety recommendations to enhance and improve X X
nutrition support practice and meet patient/client needs (eg, during
injectable-drug shortages, enteral misconnections)
1.4C Leads local/state/national and/or international quality initiative X
efforts to support nutrition support goals and best practices
1.4D Monitors changes to local, state, and national quality initiatives and X
leads quality improvement activities for nutrition support and
related services
1.5 Uses a systematic performance improvement (PI) model that is based on X X X
practice knowledge, evidence, research, and science for delivery of the
highest quality services
1.5A Identifies and participates in the use of an appropriate PI/quality X X X
improvement model (eg, PDCAc Cycle, Six Sigma,d Rapid Cycle
Improvement,e LEAN Thinkingf) for assessing quality of nutrition
support delivery
1.5A1 Aligns selection of performance improvement method X X X
with the model preferred by the organization where the
nutrition care is being delivered
1.5A2 Obtains training and mentors colleagues, students, and X X
members of the interprofessionalg team on PI model(s)
and leads PI initiatives
1.5A3 Develops and leads interprofessional quality improvement X
activities across the organization or system
1.6 Participates in or designs an outcomes-based management system to X X X
evaluate safety, effectiveness, quality, person-centeredness, equity,
timeliness, and efficiency of practice
1.6A Involves colleagues and others, as applicable, in systematic X X X
outcomes management
1.6A1 Collaborates with interprofessional team in promoting and X X X
measuring quality of nutrition support delivery using
systematic outcomes management
1.6A2 Prioritizes performance improvement projects based on X X
organization priorities (eg, maximize reimbursement,
regulation and accreditation requirements, achieving core
measures)

Figure 2. (continued) Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Nutrition Support. Note:
The term customer is used in this evaluation resource as a universal term. Customer could also mean client/patient/customer, family,
FROM THE ACADEMY

1.6B Defines expected outcomes X X X
1.6B1 Selects outcomes that are relevant to nutrition support X X X
delivery and are applicable to other interprofessional team
leaders/stakeholders; seeks assistance if needed
1.6B2 Identifies quality outcomes and defines targets for the X X
nutrition support population/program or organization
through evaluation, benchmarking, and monitoring
environmental trends
1.6B3 Interprets clinical, patient/client, functional, and financial X X
outcomes associated with safe, effective, and efficient
delivery of nutrition support therapy (ie, EN and PN
support)
1.6B4 Determines desired nutrition-specific outcomes for the X
patient/client population through direct evaluation,
benchmarking (eg, national standards, recognized practice
guidelines), and evaluation of environmental trends
1.6C Uses indicators that are specific, measurable, attainable, realistic, X X X
and timely (S.M.A.R.T.)
1.6C1 Identifies and uses nationally standardized and consensus- X X X
based nutrition support performance measures
1.6C2 Creates, implements, evaluates, and revises indicators to X X X
ensure they are S.M.A.R.T.
1.6D Measures quality of services in terms of structure, process, and X X X
outcomes
1.6D1 Uses and/or develops systematic quality improvement X X X
approach to collect data from multiple sources to measure
quality of services against desired outcomes
1.6D2 Uses systematic quality improvement approaches to X X X
collect and trend data regarding the population served (eg,
demographics, acuity, clinical risk factors, morbidity, and
mortality), services provided, and outcomes
1.6D3 Uses a continuous quality and process improvement X X
approach to measure use of nutrition support therapy
against its outcomes
1.6D4 Uses aggregated data to evaluate current performance X X
measurement process against expected outcomes to
determine if changes are required

FROM THE ACADEMY

1.6D5 Assesses services using culturally competent engagement X X
process in accordance with established performance
criteria to improve practice and nutrition support care
1.6D6 Assesses effectiveness of nutrition support therapy in X X
diverse populations
1.6D7 Creates a data collection system to capture information for X
quality/outcome measurement
1.6D8 Conducts data analysis, develops report of outcomes and X
improvement recommendations, and disseminates
findings
1.6E Incorporates electronic clinical quality measures to evaluate and X X X
improve care of patients/clients at risk for malnutrition or with
malnutrition (www.eatrightpro.org/emeasures)
1.6E1 Ensures that screening for nutrition risk is a component of X X X
admission process or incorporates into nutrition
assessment using evidence-based screening tools for the
setting and/or population
1.6E2 Collects data using clinical quality measures applicable to X X
population and setting (eg, screening timeframes, severity
of malnutrition, and services provided [eg, nutrition
assessment, nutrition and/or dietary supplements, EN or
PN, nutrition counseling, post-discharge services])
1.6F Documents outcomes and patient reported outcomes (eg, X X X
PROMISh)
1.6F1 Documents outcomes related to patient/client population X X X
reported quality of life, depression, or other indicators and
participates in evaluation and reporting
1.6F2 Uses documented outcomes to reinforce current practice X X
or implement changes in practice
1.6F3 Synthesizes and shares effectiveness outcomes on X
programs and services with the nutrition and nutrition
support communities
1.6G Participates in, coordinates, or leads program participation in X X X
local, regional, or national registries and data warehouses used for
tracking, benchmarking, and reporting service outcomes
1.6G1 Actively promotes the inclusion of RDN-provided medical X X
nutrition therapy (MNT) and nutrition support service
components in local, regional, and/or national data
registries

FROM THE ACADEMY

1.7 Identifies and addresses potential and actual errors and hazards in X X X
provision of services or brings to attention of supervisors and team
members as appropriate
1.7A Evaluates and ensures nutrition care is being delivered safely; seeks X X X
1.7A1 Refers patients/clients to appropriate services when error/ X X X
hazard is outside practitioner’s scope of practice
1.7A2 Identifies and educates patients/clients/advocates/ X X X
caregivers and other health care professionals regarding
potential drug-food/nutrient interactions
1.7A3 Establishes processes and guidelines to prevent harm X X
associated with nutrition support therapy (eg, enteral
feeding tube misconnection, refeeding syndrome)
1.7A4 Maintains awareness of problematic product names, drug X X
classes, and error-prevention recommendations provided
by ISMP,i FDA,j and USPk
1.7A5 Collaborates and leads an analysis of safety event X
reporting data and intervenes in sentinel events and near
misses associated with EN and PN therapy (eg, medication
or compounding errors, infection control, safe delivery)
1.8 Compares actual performance to performance goals (eg, Gap Analysis, X X X
SWOT Analysis [Strengths, Weaknesses, Opportunities, and Threats], PDCA
Cycle, DMAIC [Define, Measure, Analyze, Improve, Control])
1.8A Reports and documents action plan to address identified gaps in X X X
care and/or service performance
1.8B Evaluates individual and organization performance in comparison to X X
goals and expected outcomes
1.8C Benchmarks department/organization performance with national X X
programs and standards
1.9 Evaluates interventions and workflow process(es) and identifies service and X X X
delivery improvements
1.9A Uses evaluation data and/or collaborates with interprofessional team X X X
to identify program/service improvements
1.9B Conducts data analysis to evaluate the success of action plans in X X
meeting patient/client and program goals; develops report of
outcomes, and provides recommendations

FROM THE ACADEMY

1.9C Guides the development, testing, and redesign of organization/ X
program evaluation systems
1.10 Improves or enhances patient/client/population care and/or services X X X
working with others based on measured outcomes and established goals
1.10A Adjusts services and programs based on data and review of current X X X
evidence-based information in collaboration with interprofessional team
1.10B Leads or collaborates in creating and improving systems, processes, X X
and programs that support organization nutrition support-related
core values and evidence-based guidelines for safe, quality care
1.10C Translates continuous quality improvement data to interprofessional X
team and manages changes in processes
Examples of Outcomes for Standard 1: Quality in Practice

Actions are within scope of practice and applicable laws and regulations
National quality standards and best practices are evident in customer-centered services
Performance improvement systems specific to program(s)/service(s) are established and updated as needed and are
evaluated for effectiveness in providing desired outcomes data and striving for excellence in collaboration with other
team members
Performance indicators are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)
Aggregate outcomes results meet pre-established criteria
Quality improvement results direct refinement and advancement of practice
Standard 2: Competence and Accountability

The registered dietitian nutritionist (RDN) demonstrates competence in and accepts accountability and responsibility for
ensuring safe, quality practice and services.
Rationale:
Competence and accountability in practice includes continuous acquisition of knowledge, skills, experience, and judgment in
the provision of safe, quality customer-centered service.
Indicators for Standard 2: Competence and Accountability

2.1 Adheres to the code(s) of ethics (eg, Academy/Commission on Dietetic X X X
Registration [CDR], other national organizations, and/or employer code of ethics)
2.1A Explains ethical responsibilities to patients/clients, peers, and other X X X
professionals

FROM THE ACADEMY

2.1A1 Analyzes ethics issues and addresses within the code of X X X
ethics; seeks guidance through consultation with
appropriate professionals
2.1A2 Develops an ethical philosophy with the interprofessional X X
team
2.1A3 Serves as a resource for other health care practitioners on X
ethical issues related to nutrition support therapy
2.1B Educates patients/clients/consumers/customers and other caregivers X X X
on ethical issues related to nutrition support therapy for when
making informed choices for type of nutrition care; seeks assistance
if needed
2.2 Integrates the Standards of Practice (SOP) and Standards of Professional X X X
Performance (SOPP) into practice, self-evaluation, and professional
development
2.2A Integrates applicable focus area(s) SOP and/or SOPP into practice X X X
(www.eatrightpro.org/sop) (eg, Nephrology Nutrition, Pediatric
Nutrition, Diabetes Care, Post-Acute Long-Term Care)
2.2B Uses the SOP and SOPP for RDNs in Nutrition Support to assess X X X
performance at the appropriate level of practice; develops and
implements a professional development plan to improve quality of
practice and performance to advance practice
2.2C Reviews and recommends updates to organization policies, X X
guidelines, and/or materials (eg, job descriptions, performance
competencies, career ladders, acceptable performance level)
reflecting the SOP and SOPP for RDNs in Nutrition Support; seeks
assistance and approvals, if needed
2.2D Uses advanced practice experience and knowledge to define specific X
activities for levels of practice reflecting the SOP and SOPP for RDNs
in Nutrition Support
2.3 Demonstrates and documents competence in practice and delivery of X X X
customer-centered service(s)
2.3A Participates in the health care institution’s nutrition support-related X X X
activities to gain knowledge and skills
2.3B Demonstrates nutrition support therapy knowledge, skills, and X X
competence in areas such as: MNT, nutrition pharmacology, nutrition
pathophysiology, research basis of practice, counseling,
comorbidities

FROM THE ACADEMY

2.3C Exemplifies advanced skills, knowledge, and competence related to X
nutrition support therapy (eg, MNT, nutrition pharmacology,
nutrition pathophysiology)
2.4 Assumes accountability and responsibility for actions and behaviors X X X
2.4A Identifies, acknowledges, and corrects errors X X X
2.4B Exhibits professionalism and strives for improvement in practice (eg, X X X
manages change effectively, demonstrates assertiveness, listening
and conflict resolution skills; and ability to build coalitions); seeks
2.4C Develops and implements nutrition support-related policies and X X
procedures that ensure staff accountability and responsibility;
collaborates with interprofessional team and/or seeks guidance if
needed
2.5 Conducts self-evaluation at regular intervals X X X
2.5A Identifies needs for professional development X X X
2.5B Prioritizes primary focus areas for professional development X X X
2.5C Actively pursues nutrition support continuing education X X X
opportunities locally, regionally, and nationally
2.5D Outlines a plan to meet identified needs (eg, continuing education X X X
activities, engaging in mentor/mentee program, additional nutrition
support-related coursework)
2.5D1 Analyzes most effective methods to meet identified X X
needs
2.5E Outlines and prioritizes professional goals to assure that the X X X
developed plan is implemented most effectively
2.6 Designs and implements plans for professional development X X X
2.6A Develops plan and documents professional development activities X X X
in career portfolio (eg, organizational policies and procedures,
credentialing agency[ies])
2.6A1 Pursues new opportunities for growth in professional X X X
practice by obtaining the knowledge, skills, experience,
and mentoring needed to qualify for privileging or medical
director approval for new service(s), or a specialty
certification
2.6A2 Designs and implements a continuing education plan for X X
advancing nutrition support knowledge and skills

FROM THE ACADEMY

2.6A3 Includes a plan for achieving the knowledge, skills, and X X
experience needed to qualify for or maintain
certification(s) (eg, CNSC, CSPCC, CSR, RDN-AP) to support
role(s) and responsibilities
2.6A4 Seeks resources and mentors outside of the field of X
nutrition support to gain skills that will translate into
nutrition support practice (eg statistics class to improve
ability to analyze and report results of research)
2.6B Selects and works with a mentor to guide nutrition support X X X
professional advancement
2.7 Engages in evidence-based practice and uses best practices X X X
2.7A Recognizes strengths and limitations of current information/ X X X
research/evidence when making recommendations; seeks assistance
if needed
2.7B Evaluates practice for consistency with current evidence-based X X X
research and practice guidelines in nutrition support and other areas
applicable to patient/client population and practice setting
2.7C Investigates evidence-based research findings and incorporates into X X
current practice
2.7D Uses advanced training, research, and emerging theories to manage X
complex cases (eg, multiple comorbidities, complications) in the
nutrition support population
2.8 Participates in peer review of others as applicable to role and X X X
responsibilities
2.8A Engages in peer review activities consistent with setting, X X
responsibilities, and patient/client population (eg, peer evaluation,
peer supervision, clinical chart review, and performance evaluations)
2.8B Demonstrates knowledge and skills to train, mentor, and guide X X
credentialed nutrition and dietetics practitioners and other support
staff
2.8C Creates and improves nutrition support evaluation tools and X
processes of peer-/self-review process
2.9 Mentors and/or precepts others X X X
2.9A Participates in mentoring entry-level and competent-level RDNs in X X X
nutrition support; and serves as preceptor for nutrition and dietetics
students/interns; seeks to be inclusive of diverse individuals

FROM THE ACADEMY

2.9B Contributes to the educational and professional development of X X X
credentialed nutrition and dietetics practitioners, students/interns,
and health care professionals through formal and informal training
activities
2.9C Participates in mentor programs with credentialed nutrition and X X
dietetics practitioners and other health care professionals
2.9D Provides case consultation and supervises other credentialed X X
nutrition and dietetics practitioners (eg, RDNs new to nutrition
support) in complex patient/client management
2.9E Mentors individuals in advancing a specific skill set, such as feeding X
tube placement or indirect calorimetry interpretation
2.9F Designs, operates, and evaluates mentor programs with credentialed X
nutrition and dietetics practitioners and other health care
professionals (eg, resident training, fellow training, RDN obtaining a
doctorate degree)
2.10 Pursues opportunities (education, training, credentials, certifications) to X X X
advance practice in accordance with laws and regulations, and
requirements of practice setting
2.10A Participates in virtual and/or in-person continuing education X X X
opportunities relevant to nutrition support practice locally,
regionally, and nationally
2.10B Investigates benefits of participation in nutrition support practice X X X
organizations and others to support career goals
2.10C Develops and implements a plan for achieving/advancing X X X
knowledge and practice (eg, specialty certification, research
participation, speaking engagements)
2.10D Obtains and maintains specialist credentials(s) (eg, CNSC, CSPCC, X X
CSR, RDN-AP)
2.10E Develops programs, tools, and resources in support of assisting RDNs X
to obtain advanced practice certification in nutrition support
Examples of Outcomes for Standard 2: Competence and Accountability

Practice reflects:
B Code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)
B Scope of Practice, Standards of Practice and Standards of Professional Performance
B Evidence-based practice and best practices
B CDR Essential Practice Competencies and Performance Indicators
Practice incorporates successful strategies for interactions with individuals/groups from diverse cultures and
backgrounds

FROM THE ACADEMY
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

3.1 Contributes to or leads in development and maintenance of programs/ X X X
services that address needs of the customer or target population(s)
3.1A Aligns program/service development with the mission, vision, X X X
principles, values, and service expectations and outputs of the
organization/business
3.1A1 Develops and manages nutrition support programs tailored X X
to the needs of the organization and the patient/client
population
3.1A2 Demonstrates need for specific nutrition supporterelated X X
services (eg, home EN feeding clinic)
3.1A3 Leads an interprofessional nutrition support team, using X
expert knowledge and critical thinking to develop and
implement nutrition support team services and policies
3.1A4 Designs, promotes, and seeks executive and/or medical staff X
commitment to new services that will meet organization
goals and support desired nutrition outcomes
3.1B Uses the needs, expectations, and desired outcomes of the X X X
customers/populations (eg, patients/clients, families, community,
decision makers, administrators, client organization[s]) in program/
service development
3.1B1 Accommodates anticipated patient/client needs and X X
identified goals and objectives in nutrition support therapy
program development and delivery

FROM THE ACADEMY

3.1B2 Leads systems of nutrition care and services for the provision X
of nutrition support therapies, coordinating nutrition care
and services with other departments, home care services
3.1B3 Synthesizes the results and outcomes of the services and X
programs to create new and unique offerings to meet
patients/clients and advocates/caregivers needs
3.1C Makes decisions and recommendations that reflect stewardship of X X X
time, talent, finances, and environment
3.1C1 Advocates for staffing and resources that support patient/ X X
client population, census/caseload, acuity, programs and
services, and goals
3.1D Proposes programs and services that are customer-centered, X X X
culturally appropriate, and minimize disparities
3.1D1 Adapts practices to minimize or eliminate identified health X X X
disparities associated with culture, race, gender,
socioeconomic status, age, and other factors
3.1D2 Develops/maintains programs and services that are tailored X X
to patient/client population characteristics, disease states,
health status, and social determinants of health
3.2 Promotes public access and referral to credentialed nutrition and dietetics X X X
practitioners for quality food and nutrition programs and services
3.2A Contributes to or designs referral systems that promote access to X X X
qualified, credentialed nutrition and dietetics practitioners
3.2A1 Participates in or develops processes to receive or make X X
referrals to other providers that address the needs of the
nutrition support population (eg, pharmacist, respiratory
therapist, mental/behavioral health professional, physical
therapist, speech-language pathologist, bariatric surgery
center)
3.2A2 Designs referral systems that match qualified RDNs in X X
nutrition support practice with the needs of the public
3.2A3 Designs, directs, and coordinates referral process and X
systems
3.2B Refers customers to appropriate providers when requested services X X X
or identified needs exceed the RDN’s individual scope of practice
3.2B1 Collaborates with health care practitioners to facilitate X X X
referrals when patient/client need(s) is outside the RDN’s
scope of practice

FROM THE ACADEMY

3.2B2 Verifies potential referral provider’s care reflects evidence- X X X
based information/research and professional standards of
practice
3.2B3 Establishes and maintains networks to support the overall X X
care and needs of the patients/clients receiving nutrition
support therapy
3.2C Monitors effectiveness of referral systems and modifies as needed to X X X
achieve desirable outcomes
3.2C1 Tracks data to evaluate efficiency and effectiveness of the X X X
nutrition referral processes
3.2C2 Manages and/or leads data review and revision of the X X
nutrition referral process and collaborative tools within the
3.2C3 Leads the interprofessional team and other health care X
providers to review data and update the nutrition referral
process and tools when needed
3.3 Contributes to or designs customer-centered services X X X
3.3A Assesses needs, beliefs/values, goals, resources of the customer, and X X X
social determinants of health
3.3A1 Recognizes the influence that culture, health literacy, and X X X
socioeconomic status have on patients’/clients’ health/illness
experiences and population’s use of and access to health
care services
3.3A2 Anticipates the needs, goals, and resources of patients/ X X
clients receiving nutrition support therapy
3.3A3 Participates in or conducts needs assessment considering X X
social determinants of health in collaboration with
interprofessional team and community stakeholders to
identify patient/client population’s needs and services that
are available
3.3B Uses knowledge of the customer’s/target population’s health X X X
conditions, cultural beliefs, and business objectives/services to guide
design and delivery of customer-centered services
3.3B1 Adapts program/service practices to meet the needs of an X X X
ethnically and culturally diverse population
3.3B2 Participates in or plans, develops, and implements systems X X
of nutrition care and services reflecting needs of the
population

FROM THE ACADEMY

3.3C Communicates principles of disease prevention and behavioral X X X
change appropriate to the customer or target population
3.3C1 Advises on and uses systems or tools for communicating X X
disease prevention and behavioral change principles with
specific populations
3.3C2 Designs systems or tools to communicate disease prevention X
and behavioral change with specific populations
3.3D Collaborates with the customers to set priorities, establish goals, and X X X
create customer-centered action plans to achieve desirable
outcomes
3.3D1 Collaborates with patients/clients/caregivers, health care X X X
providers, and other support resources to create person-
centered action plans that reflect the patients’/clients’ needs,
wishes, desired outcomes, and program/service goals;
documents decisions in medical record or according to
organization/program guidelines
3.3E Involves customers in decision making X X X
3.3E1 Designs nutrition support therapy regimens according to X X X
patients’/clients’ needs and lifestyles with consideration of
and input from advocate/caregivers, when appropriate
3.3E2 Facilitates patients’/clients’/advocates’ participation in health X X
care decision making and goal setting, including preferences
for use of EN or PN, and as part of end-of-life care when
applicable
3.3E3 Develops and/or facilitates interprofessional team X
collaboration on design of nutrition support treatment plans
to address patients/clients with complex needs
3.4 Executes programs/services in an organized, collaborative, cost effective, and X X X
customer-centered manner
3.4A Collaborates and coordinates with peers, colleagues, stakeholders, X X X
and within interprofessional teams
3.4A1 Works with interprofessional team for education/skill X X X
development and to demonstrate role of RDN and nutrition
in care of individuals receiving EN or PN
3.4A2 Collaborates with the interprofessional team to define the X X
role of team members in identifying and monitoring safety
practices in the delivery of nutrition support therapy

FROM THE ACADEMY

3.4A3 Facilitates interprofessional discussions and care planning X X
for patients/clients with complex nutrition needs to achieve
nutrition outcomes (eg, traumatic brain injury, post-
transplantation, post-bariatric surgery)
3.4B Uses and participates in, or leads in the selection, design, execution, X X X
and evaluation of customer programs and services (eg, nutrition
screening system, medical and retail foodservice, electronic health
records, interprofessional programs, community education, grant
management)
3.4B1 Incorporates standards for nutrition and nutrition support X X X
therapy (adult and pediatric) based on evidence-based
guidelines and recommendations in design of programs and
services; seeks assistance if needed
3.4B2 Coordinates process to review and revise nutrition support X X
screening tools and procedures within the interprofessional
nutrition support team or service
3.4B3 Guides the development, implementation, and evaluation of X
nutrition support care, programs, screening initiatives, and
services for individuals
3.4C Uses and develops or contributes to selection, design and X X X
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 regulations
3.4C1 Collaborates/participates in the development and revision of X X X
policies, procedures, and evidence-based practice tools for
nutrition support-related services applicable to population
served by setting(s)
3.4C2 Plans and implements systems of care and services for X X
nutrition support therapy predicated on evidence-based
strategies to prevent and/or treat disease in collaboration
with others
3.4C3 Collaborates with the interprofessional team and orients staff X X
on new or revised policies/procedures/protocols; monitors
success/follow-through, and amends as needed
3.4C4 Leads interprofessional process of monitoring, evaluating, X
improving, and implementing nutrition support-related
protocols, guidelines, and practice tools

FROM THE ACADEMY

3.4D Uses and participates in or develops processes for order writing and X X X
other nutrition-related privileges, in collaboration with the medical
staff,l or medical director (eg, post-acute care settings, dialysis
center, public health, community, free-standing clinic settings),
consistent with state practice acts, federal and state regulations,
organization policies, and medical staff rules, regulations, and
bylaws
3.4D1 Uses and participates in or leads development of X X X
processes for privileges or other facility-specific processes
related to (but not limited to) implementing physician/
non-physician practitionerm-driven delegated orders or
protocols, initiating or modifying orders for therapeutic
diets, medical foods/nutrition supplements, dietary
supplements, EN and PN, laboratory tests, medications,
and adjustments to fluid therapies or electrolyte
replacements
3.4D1i Adheres to organization- and medical staff/ X X X
medical directoreapproved protocols and/or
privileges for ordering or recommending
therapeutic diets and nutrition-related services
(eg, oral nutrition and/or vitamin/mineral
supplements; EN or PN; supplemental water);
seeks assistance if needed
3.4D1ii Contributes to organization/medical staff process X X
for identifying RDN privileges or delegated
orders to support nutrition support care and
services (eg, ordering or revising diet, medical
food/nutrition supplements, EN or PN, vitamin
and mineral supplements, or other nutrition-
related orders [eg, ordering and inserting
nasoenteric feeding tubes])
3.4D1iii Negotiates for and gains nutrition privileges at a X
systems level for new advances in practice
3.4D2 Uses and participates in or leads development of X X X
processes for privileging for provision of nutrition-related
services, including (but not limited to) initiating and
performing bedside swallow screenings, inserting and
monitoring nasoenteric feeding tubes, providing home
enteral nutrition or infusion management services (eg,
ordering formula and supplies), and indirect calorimetry
measurements

FROM THE ACADEMY

3.4D2i Assures that role and direct care activities with X X
home infusion patients/clients are consistent
with home health/infusion program policy and
physician orders, and demonstrated and
documented competence
3.4D2ii Collaborates in the development of RDN X
privileges and/or physician-driven protocols for:
inserting and managing nasoenteric
feeding tubes
conducting and/or interpreting the results
of indirect calorimetry measurements
assessing body composition using DEXA,n
CTo scans, and ultrasound
3.4E Complies with established billing regulations, organization policies, X X X
grant funder guidelines, if applicable to role and setting, and
adheres to ethical and transparent financial management and billing
practices
3.4F Communicates with the interprofessional team and referring party X X X
consistent with the HIPAA rules for use and disclosure of customer’s
protected health information (PHI)
3.4F1 Follows regulations and organization/program policies for X X X
accessing, transporting, and storing information containing
PHI when working in multiple sites; seeks assistance if
needed
3.4F2 Develops processes and tools to monitor adherence to X X
HIPAA rules and/or address breaches in the protection of PHI
and use of electronic medical records (onsite or through
remote access)
3.5 Uses professional, technical, and support personnel appropriately in the X X X
delivery of customer-centered care or services in accordance with laws,
regulations, and organization policies and procedures
3.5A Assigns activities, including direct care to patients/clients, consistent X X X
with the qualifications, experience, and competence of professional,
technical, and support personnel
3.5A1 Determines capabilities/expertise of professional, technical, X X
and support staff working with patients/clients to
appropriately delegate tasks

FROM THE ACADEMY

3.5B Supervises professional, technical, and support personnel X X X
3.5B1 Trains professional, technical, and support personnel and X X
evaluates and documents their competence/skills following
organization/program guidelines
3.6 Designs and implements food delivery systems to meet the needs of X X X
customers
3.6A Collaborates in or leads the design of food delivery systems to X X X
address health care needs and outcomes (including nutrition status),
ecological sustainability, and to meet the culture and related needs
and preferences of target populations (eg, health care patients/
clients, employee groups, schools, child and adult day care centers)
3.6A1 Collects data and provides feedback on current food, EN X X X
and/or PN delivery systems serving individuals receiving
nutrition support therapy in health care and community
settings
3.6B Participates in, consults/collaborates with, or leads the development X X X
of menus to address health, nutritional, and cultural needs of target
population(s) consistent with federal, state or funding source
regulations or guidelines
3.6B1 Develops evidence-based disease or condition-specific X X
guidelines for oral diet and nutrition supplement
management for patients/clients who receive nutrition
support therapy
3.6B2 Designs or provides consultation on in-house or X X
commercially prepared nutrition supplement options that
reflect and encourage normalized eating for individuals
requiring supplemental EN or PN support
3.6C Participates in, consults/collaborates with, or leads interprofessional X X X
process for determining medical foods/nutrition supplements,
dietary supplements, EN and PN formularies, and delivery systems
for target population(s)
3.6C1 Actively participates in the process for determining EN and/ X X X
or PN formulas and delivery systems
3.6C2 Provides guidance regarding medical foods/nutrition X X
supplements, EN or PN formulas in accordance with best
practices (eg, ASPEN, Academy, American Academy of
Pediatrics)

FROM THE ACADEMY

3.6C3 Collaborates in or leads: X
interprofessional process for determining EN and PN
formulary and associated supplies
decision-making processes in case of shortages (eg,
including emergencies or catastrophic events) and
substitutions needed in enteral and/or parenteral
formulations and delivery systems based on patient/
client population and safety issues
3.7 Maintains records of services provided X X X
3.7A Documents according to organization policies, procedures, X X X
standards, and systems including electronic health records
3.7A1 Uses and participates in the design/revision of electronic X X X
health records applicable to setting and strategies for
manual documentation as a backup
3.7A2 Develops documentation/data collection procedures X X
specifically suitable for nutrition support therapy
3.7A3 Spearheads development of electronic or other tools for X
measuring and reporting outcomes of nutrition support
therapy
3.7B Implements data management systems to support interoperable X X X
data collection, maintenance, and utilization
3.7B1 Develops data collection tools or collaborates with the X X
interprofessional team to capture nutrition supportespecific
data through electronic health records
3.7B2 Seeks opportunities to contribute expertise to national X
bioinformatics/medical informatics projects, as applicable/
requested
3.7C Uses data to document outcomes of services (ie, staff productivity, X X X
cost/benefit, budget compliance, outcomes, quality of services) and
provide justification for maintenance or expansion of services
3.7C1 Analyzes and uses data to communicate value of nutrition X X
and nutrition support services in relation to patient/client
population and organization outcomes/goals
3.7D Uses data to demonstrate program/service achievements and X X X
compliance with accreditation standards, laws, and regulations

FROM THE ACADEMY

3.7D1 Prepares and presents nutrition care and service outcomes X X
data for organization and accreditation organization if
applicable; seeks assistance if needed
3.8 Advocates for provision of quality food and nutrition services as part of X X X
public policy
3.8A Communicates with policy-makers regarding the benefit/cost of X X X
quality food and nutrition services
3.8A1 Considers organization policies related to participating in X X X
advocacy activities
3.8A2 Advocates for nutrition support therapy at the policy level X X X
(eg, addressing drug shortages, reimbursement)
3.8A3 Promotes provision of and access to nutrition support X X
therapy in health care organizations and at home by
participating in legislative and policy-making activities that
influence health services and practices
3.8A4 Interacts and serves as a resource with legislators, payers, X X
and policy makers to influence nutrition support care and
services (eg, providing testimony at legislative and
regulatory hearings and meetings)
3.8A5 Leads advocacy efforts in nutrition support by: X
authoring articles or delivering presentations
contributing to development/review/comments/
recommendations on policy, statutes, administrative
rules and regulations
participating on state regulatory boards to influence
regulations that may impact future practice
3.8B Advocates in support of food and nutrition programs and services X X X
for populations with special needs and chronic conditions
3.8B1 Reviews evidence-based research to identify and advocate X X X
for special needs populations whose health status will
benefit from nutrition support therapy
3.8B2 Identifies needs and opportunities for nutrition support X X
population advocacy and participates in efforts to address
issue(s)

FROM THE ACADEMY

3.8C Advocates for protection of the public through multiple avenues of X X X
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)
3.8C1 Participates in regional or national activities related to X X
nutrition support policy and services; seeks opportunities for
collaboration
Examples of Outcomes for Standard 3: Provision of Services

Program/service design and systems reflect organization/business mission, vision, principles, values, and customer needs
and expectations
Customers participate in establishing program/service goals and customer-focused action plans and/or nutrition
interventions (eg, in-person or via telehealth)
Customer-centered needs and preferences are met
Customers are satisfied with services and products
Customers have access to nutrition support assistance and food and nutrition services
Formularies reflect the cultural, health and/or nutritional needs of target population(s) and consideration of ecological
sustainability
Evaluations reflect expected outcomes and established goals
Effective screening and referral services are established or implemented as designed
Professional, technical, and support personnel are supervised when providing nutrition care to customers
Ethical and transparent financial management and billing practices are used per role and setting
Standard 4: Application of Research

The registered dietitian nutritionist (RDN) applies, participates in, and/or generates research to enhance practice. Evidence-
based practice incorporates the best available research/evidence and information in the delivery of nutrition and dietetics
services.
Rationale:
Application, participation, and generation of research promote improved safety and quality of nutrition and dietetics practice
and services.
Indicators for Standard 4: Application of Research

4.1 Reviews best available research/evidence and information for application to X X X
practice

FROM THE ACADEMY

4.1A Understands basic research design and methodology X X X
4.1B Uses experience and critical thinking to evaluate strength of original X X
research and evidence-based guidelines relevant to nutrition support,
including limitations and potential bias(es)
4.1C Applies evidence-based tools/resources (eg, Academy EAL, practice X X
guidelines) to stimulate awareness and integration of current evidence
into organization care protocols to standardize clinical practice
4.1D Leads application of new evidence in the practice setting X
4.2 Uses best available research/evidence and information as the foundation for X X X
evidence-based practice
4.2A Applies evidence-based practice guidelines to provide consistent, safe, X X X
effective quality care for patients/clients receiving nutrition support;
consults with more experienced practitioner for guidance as needed
4.2B Incorporates evidence-based research into practice and is able to X X
summarize and cite current literature that supports the optimal
approach for provision of safe, effective nutrition support therapy
4.2C Critically evaluates and applies available scientific literature in X
situations where evidence-based guidelines for nutrition support are
not yet established (eg, multisystem disease processes)
4.3 Integrates best available research/evidence and information with best X X X
practices, clinical and managerial expertise, and customer values
4.3A Assesses and addresses system barriers and facilitators to adoption of X X
evidence-based policies and procedures
4.3B Incorporates knowledge of cultural diversity when integrating research X X
in a specific patient/client population
4.4 Contributes to the development of new knowledge and research in nutrition X X X
and dietetics
4.4A Participates in efforts to apply research to practice (eg, journal clubs, X X X
professional discussion groups, collection of client baseline/outcomes
data, listserv participation)
4.4B Participates in practice-based research networks (eg, Academy’s X X X
Nutrition Research Network or EAL workgroup) and the development
and/or implementation of practice-based research, national research
databases; and adheres to Institutional Review Board (IRB) protocols
and confidentiality guidelines
4.4C Mentors others in identifying and applying best available research/ X X
evidence and integrating best practices
4.4D Designs research study protocol(s) to address a clinical research X X
question; uses resources to help guide the process, if needed

FROM THE ACADEMY

4.4E Identifies and initiates research relevant to nutrition support practice; acts X
as principal or co-investigator as part of collaborative research or with
health care teams examining nutrition and nutrition support therapy
4.4F Serves as advisor, preceptor, and/or committee member for graduate- X
and doctoral-level research
4.4G Develops or collaborates on research grant proposals and professional X
conference request for proposals to support continuing education of
scientific community about nutrition support
4.5 Promotes application of research in practice through alliances or X X X
collaboration with food and nutrition and other professionals and
organizations
4.5A Identifies research issues/questions and participates in studies related X X X
to nutrition support care and services
4.5B Collaborates with interprofessional and/or interorganizational teams to X X
perform and disseminate research on nutrition support
4.5C Leads interprofessional and/or interorganizational collaborative X
research activities and integration of research data into publications
and presentations related to nutrition support
Examples of Outcomes for Standard 4: Application of Research

Evidence-based practice, best practices, clinical and managerial expertise, and customer values are integrated in the
delivery of nutrition and dietetics services
Customers receive appropriate services based on the effective application of best available research/evidence and information
Best available research/evidence and information is used as the foundation of evidence-based practice
Standard 5: Communication and Application of Knowledge

The registered dietitian nutritionist (RDN) effectively applies knowledge and expertise in communications.
Rationale:
The RDN works with others to achieve common goals by effectively sharing and applying unique knowledge, skills, and
expertise in food, nutrition, dietetics, and management services.
Indicators for Standard 5: Communication and Application of Knowledge

5.1 Communicates and applies current knowledge and information based on X X X
evidence

FROM THE ACADEMY

5.1A Demonstrates critical thinking and problem-solving skills when X X X
communicating with others
5.1A1 Demonstrates the ability to convey comprehension of X X
foundational nutrition support concepts to other health care
practitioners, patients/clients, and the public
5.1A2 Demonstrates the ability to convey complex concepts to X
other health care practitioners. patients/clients, and the
public
5.1B Interprets regulatory, accreditation, and reimbursement programs and X X
standards for organizations and providers that are specific to nutrition
support (eg, Centers for Medicare and Medicaid Services [CMS], The
Joint Commission)
5.1C Evaluates public health trends and epidemiological reports common in X X
patient/client population receiving nutrition support therapy, and
applies data in clinical practice, professional activities, and work
settings
5.1D Serves as an expert resource/opinion leader for colleagues, other X
health care practitioners, the community, and outside agencies related
to nutrition support therapy
5.2 Selects appropriate information and the most effective communication X X X
method or format that considers customer-centered care and the needs of
the individual/group/population
5.2A Uses communication methods (ie, oral, print, one-on-one, group, X X X
visual, electronic, and social media) targeted to various audiences
5.2A1 Determines the most appropriate information and best X X X
educational method to present/disseminate information
based on the level of understanding of the individual and/or
target audience (eg, advocate, care providers, professional
colleagues, administrators, or the community)
5.2B Uses information technology to communicate, disseminate, manage X X X
knowledge, and support decision making
5.2B1 Identifies and uses web-based/electronic nutrition support X X X
tools/resources (eg, EN calculation apps) and telehealth
platforms within worksite as appropriate
5.2B2 Develops innovative approaches to using current information X X
technology to deliver up-to-date information to nutrition
support practitioners, other health care professionals, and the
public

FROM THE ACADEMY

5.2B3 Leads the development of patient-/client-, and system- X
specific technology that effectively conveys nutrition and
nutrition supporterelated issues to diverse audiences
5.3 Integrates knowledge of food and nutrition with knowledge of health, X X X
culture, social sciences, communication, informatics, sustainability, and
management
5.3A Applies current and emerging scientific knowledge of nutrition support X X X
when considering population’s culture, health status, behavior barriers,
communication skills, and interprofessional team involvement; seeks
guidance as needed
5.3B Demonstrates ability to integrate and communicate new knowledge to X X
identified audience
5.3C Leads the integration of current and emerging knowledge from clinical X
research findings and consultation, in the management and resolution
of complex problems in nutrition support
5.4 Shares current, evidence-based knowledge, and information with various X X X
audiences
5.4A Guides customers, families, students, and interns in the application X X X
of knowledge and skills
5.4A1 Builds and maintains collaboration among researchers, X X
educators, and decision makers to facilitate effective
knowledge transfer for health practitioners’ education
programs
5.4B Assists individuals and groups to identify and secure appropriate X X X
and available educational and other resources and services
5.4B1 Connects patients/clients/family/caregivers and support X X X
networks with programs/services and resources within the
patients’/clients’ ethnic/cultural community to positively
influence health-related decision making and outcomes
5.4B2 Contributes to development of patient/client education X X X
materials/classes
5.4B3 Establishes systematic processes to identify, track, and X X
update available nutrition support resources for patients/
clients and their family/care providers
5.4B4 Tracks and monitors use of patient/client population X
resources and impact on outcomes within the specific
ethnic/cultural community, and collaborates as appropriate

FROM THE ACADEMY

5.4C Uses professional writing and verbal skills in all types of X X X
communications
5.4D Reflects knowledge of population characteristics in communication X X X
methods (eg, literacy and numeracy levels, need for translation of
written materials and/or a translator, communication skills, and
learning, vision or hearing disabilities)
5.5 Establishes credibility and contributes as a food and nutrition resource within X X X
the interprofessional health care and management team, organization, and
community
5.5A Contributes formally and informally to the interprofessional team (eg, X X X
shares relevant articles, investigates queries, serves as nutrition subject
matter expert)
5.5B Communicates with members of the interprofessional team and other X X X
providers to promote the use of evidence-based guidelines/practices
and the EAL
5.5C Develops and/or presents programs emphasizing the safe and X X
effective delivery of nutrition support therapy
5.5D Leads interprofessional collaborations at an organization or system X
level
5.6 Communicates performance improvement and research results through X X X
publications and presentations
5.6A Presents nutrition support guidelines and research at the local level X X X
(eg, community groups, interprofessional team, colleagues)
5.6B Compiles and interprets performance improvement and research X X
findings and reports results to interprofessional team and others within
the organization
5.6C Authors peer-reviewed nutrition support publications and authoritative X X
articles for credentialed nutrition and dietetics practitioners, other
health care practitioners, and consumers
5.6D Presents evidence-based nutrition support research, guidelines, and X X
information at professional meetings and conferences (eg, local,
regional, national, or international)
5.6E Leads collation of performance improvement and research data into X
publications (eg, systematic reviews, practice and position papers), and
presentations to influence nutrition support practice
5.6F Serves in a leadership role for nutrition support- or nutrition-related X
publications (eg, editor or editorial board member of peer-reviewed
journal[s]) and program planning at regional and national levels

FROM THE ACADEMY

5.7 Seeks opportunities to participate in and assume leadership roles with local, X X X
state, and national professional and community-based organizations (eg,
government-appointed advisory boards, community coalitions, schools,
foundations, or nonprofit organizations serving the food insecure) providing
food and nutrition expertise
5.7A Serves as a nutrition support resource as an active member of local or X X X
state organizations
5.7B Serves as a nutrition support resource as an active member of X X
coalitions, task forces or advisory boards
5.7C Pursues leadership development opportunities as a subject matter X X
expert and organizes work groups in local, regional, and national
nutrition supporterelated organizations, coalitions, or advisory boards
5.7D Identifies new opportunities for leadership and cross-discipline dialogue X
to promote nutrition and dietetics practice in a broader context
Examples of Outcomes for Standard 5: Communication and Application of Knowledge

Expertise in food, nutrition, dietetics, and management is demonstrated and shared
Interoperable information technology is used to support practice
Effective and efficient communications occur through appropriate and professional use of e-mail, texting, and social media tools
Individuals, groups, and stakeholders:
B Receive current and appropriate information and customer-centered service
B Demonstrate understanding of information and behavioral strategies received
B 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

6.1 Uses a systematic approach to manage resources and improve outcomes X X X
6.1A Identifies efficient workflow patterns to optimize time management X X X
and maximize patient/client care outcomes

FROM THE ACADEMY

6.1A1 Recognizes and uses resources (eg, education X X X
materials, training tools, staff time) effectively in the
provision of nutrition support services to achieve desired
outcomes
6.1A2 Proposes changes to organization workflow patterns to X X
improve efficiency and patient/client care outcomes
6.1A3 Collaborates on adjusting staffing and/or workflow patterns X
to optimize patient/client care outcomes through efficient
use of resources
6.1B Selects clinically appropriate and cost-effective nutrition support X X X
therapy components (eg, EN formulas, PN components, equipment)
6.1B1 Develops, with the interprofessional team, guidelines for X X
clinically appropriate and cost-effective use of nutrition
support therapy
6.1B2 Analyzes and reports nutrition support therapy use and X
related costs; modifies organization/department practices
based on results in collaboration with the interprofessional
team
6.1B3 Serves as manager or coordinator of an organization’s X
nutrition support team/service (eg, physician, pharmacist,
RDN, nurse, and other disciplines according to the needs of
the organization)
6.2 Evaluates management of resources with the use of standardized X X X
performance measures and benchmarking as applicable
6.2A Uses the Standards of Excellence Metric Tool to self-assess quality in X X X
leadership, organization, practice, and outcomes for an organization
(www.eatrightpro.org/excellencetool)
6.2A1 Participates in or develops programs that meet the X X
Standards of Excellence in Nutrition and Dietetics for
Organizations
6.2B Collects or contributes data and participates in analyzing program X X X
resources/service participation and expense data to evaluate and
adjust programs and services
6.2B1 Leads and participates in data collection and analysis X X
regarding the population served, services provided, and
outcomes (eg, demographic characteristics, staff hours,
consult requests, staffing benchmarking, and payment/
revenue)

FROM THE ACADEMY

6.2B2 Analyzes productivity and/or nutrition support therapy X
product usage data and recommends or modifies
department practice based on comparison to standardized
benchmarks
6.2C Leads or facilitates periodic operational review, reflecting evaluation of X
performance and benchmarking data, to manage resources and
modifications to processes for delivery of nutrition support therapy and
services
6.3 Evaluates safety, effectiveness, efficiency, productivity, sustainability X X X
practices, and value while planning and delivering services and products
6.3A Considers safe, effective, and cost-effective nutrition support therapy X X X
during nutrition assessment and treatment process
6.3A1 Participates in evaluation, selection, and implementation of X X
new products and services to ensure safe, optimal, and cost-
effective delivery of nutrition support care and services
6.3A2 Monitors and compares impact of nutrition support therapy X
(positive, negative, no change) and cost-effectiveness of the
therapy, including product selection, equipment, monitoring,
and staffing
6.3A3 Employs mechanisms to ensure clinical effectiveness and X
patient/client safety while planning and delivering nutrition
support-related products and services
6.3B Demonstrates understanding of and adheres to regulations and X X X
accreditation standards relevant to nutrition support (eg, CMS
Conditions for Coverage/Conditions of Participation, CMS MNT
coverage guidelines when applicable, accreditation organization
standards)
6.4 Participates in quality assurance and performance improvement (QAPI) and X X X
documents outcomes and best practices relative to resource management
6.4A Participates actively in QAPI, including collecting, documenting, and X X X
analyzing data relevant to resource use (eg, fiscal, personnel, services,
materials, supplies) and recommends modifications
6.4B Uses data to modify resource management and/or delivery of services X X
(eg, staffing, triage, nutrition supplements, education materials/tools)
as necessary to achieve desired outcomes
6.4C Reviews and reports findings according to organization’s process (eg, X X
department leadership, facility committee); develops or revises
procedures in collaboration with interprofessional team, if applicable

FROM THE ACADEMY

6.4D Integrates quality measures and performance improvement processes X
into management of human and financial resources and information
technology
6.4E Shares QAPI results via professional presentations at regional and X
national levels and publishes in peer-reviewed journals
6.5 Measures and tracks trends regarding internal and external customer X X X
outcomes (eg, satisfaction, key performance indicators)
6.5A Participates in developing and/or conducting regular surveys with X X X
patients/clients/advocates, interprofessional team members,
community participants and stakeholders to assess satisfaction; seeks
6.5B Develops or modifies programs and services based on data analysis to X X
improve stakeholder (eg, patients/clients/advocates, caregivers,
employees, administration) satisfaction with nutrition support services
6.5C Resolves internal and external problems that may affect the delivery of X X
nutrition support services
6.5D Leads interprofessional team to maximize stakeholder satisfaction with X
nutrition support services
Examples of Outcomes for Standard 6: Utilization and Management of Resources

Resources are effectively and efficiently managed
Documentation of resource use is consistent with operational and sustainability goals
Data are used to promote, improve, and validate services, organization practices, and public policy
Desired outcomes are achieved, documented, and disseminated
Key performance indicators are identified in alignment with organization mission, vision, principles, and values
a
ASPEN ¼ American Society for Parenteral and Enteral Nutrition.
b
Academy ¼ Academy of Nutrition and Dietetics.
c
PDCA ¼ Plan-Do-Check-Act: A tool for continuous improvement.
d
Six Sigma ¼ a set of techniques and tools for process improvement developed by Motorola in 1986.
e
Rapid Cycle Improvement ¼ defined by the Robert Wood Johnson Foundation as a “quality improvement method that
identifies, implements and measures changes made to improve a process or a system.”14 This method is an important part of
electronic health record (EHR) implementation because it allows continual improvement in the use of EHR technology.
LEAN thinking ¼ LEAN is centered on preserving value with less work. LEAN thinking changes the focus of management to one
f
of eliminating waste and decreasing human effort. It is a production practice that considers the expenditure of resources for any
goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination.
FROM THE ACADEMY
g
Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group
of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, social workers,
speech language pathologists, and occupational and physical therapists), depending on the needs of the customer.
Interprofessional could also mean interdisciplinary or multidisciplinary.
h
PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/
index) is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. PROMIS is a
web-based resource and is publicly available.
i
ISMP ¼ Institute for Safe Medication Practices (www.ismp.org/).
j
FDA ¼ US Food and Drug Administration (www.fda.gov/home).
k
USP ¼ US Pharmacopeia (www.usp.org/).
l
Medical staff: A medical staff is composed of doctors of medicine or osteopathy and may in accordance with state law,
including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to
be eligible for appointment by the governing body.7
m
Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse
specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist,
anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a
facility’s governing body and medical staff must be in accordance with state law.7,8 The term privileging is not referenced in the
CMS long-term care (LTC) Regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities
effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending
physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services
to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law and organization policies.10,11
n
DEXA ¼ dual energy x-ray absorptiometry.
o
CT ¼ computed tomography.

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FROM THE ACADEMY

Standards of Practice and Professional Performance

Academy of Nutrition and Dietetics and

Resource Address Description

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Resource Address Description

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Resource Address Description

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Resource Address Description

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Standards of Practice for Registered Dietitian Nutritionists in Nutrition Support

Indicators for Standard 1: Nutrition Assessment

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Indicators for Standard 1: Nutrition Assessment

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Indicators for Standard 1: Nutrition Assessment

Seeks assistance if needed

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Indicators for Standard 1: Nutrition Assessment

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Indicators for Standard 1: Nutrition Assessment

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Indicators for Standard 1: Nutrition Assessment

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Indicators for Standard 1: Nutrition Assessment

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Indicators for Standard 1: Nutrition Assessment

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Indicators for Standard 1: Nutrition Assessment

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Indicators for Standard 1: Nutrition Assessment

Examples of Outcomes for Standard 1: Nutrition Assessment

Standard 2: Nutrition Diagnosis

Indicators for Standard 2: Nutrition Diagnosis

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Indicators for Standard 2: Nutrition Diagnosis

2.2C Recognizes nutrition support-related problems in the context of X X

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Indicators for Standard 2: Nutrition Diagnosis

Examples of Outcomes for Standard 2: Nutrition Diagnosis

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Standard 3: Nutrition Intervention/Plan of Care

Indicators for Standard 3: Nutrition Intervention/Plan of Care

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Indicators for Standard 3: Nutrition Intervention/Plan of Care

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Indicators for Standard 3: Nutrition Intervention/Plan of Care

3.6A5 Determines micronutrient content of EN/PN formulation X X

3.6A6 Determines micronutrient supplementation required in X

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Indicators for Standard 3: Nutrition Intervention/Plan of Care

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Indicators for Standard 3: Nutrition Intervention/Plan of Care

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Indicators for Standard 3: Nutrition Intervention/Plan of Care

3.12A1v Collaborates with the clinical pharmacist to X X

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Indicators for Standard 3: Nutrition Intervention/Plan of Care