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Frequently Asked Questions Regarding the Role of the DTR

The following list of frequently asked questions was developed in December 2006**[i] and expanded in September 2007.

What does Centers for Medicare & Medicaid Services say about direct patient care in end-stage renal disease?
It is CMS’ expectation that direct patient care (nutrition assessments and patient counseling) in end-stage renal disease facilities be provided by the registered dietitian with at least one year of clinical experience after internship – supervised practice does not count. This translates to a total of five to six years of education and training. For that reason, neither registered dietitians with less than one year of clinical experience nor dietetic technicians, registered meet CMS requirements for the qualified dietitian in end-stage renal disease facilities. Dietetic technicians, registered may perform functions as they do in other facilities, including calorie counts, screens and diet histories.
What issues affect the DTR who is working with little or no supervision by an RD or LD?
DTRs who work with little or no RD supervision in regulated facilities are placing themselves and their employers at risk, as are RDs who fail to provide direct clinical supervision. State agencies may investigate and cite non-compliant facilities, and occupational licensing boards may consider revoking the registered dietitian’s license.
How do you define assessment? In many hospitals, rehabilitation and long-term care facilities, the DTR assesses the low risk and moderate risk patients and the RD assesses high risk patients. In the course of doing a screen, is it not necessary to assess the patient to determine level of risk? Are their certain parts of the assessment the DTR is not to do?
Healthcare is regulated at the state level and the definition for assessment is not necessarily the same for each state. It is the purview of each regulatory agency and accrediting organization for definitions of screening and assessment within the context of the healthcare facility or program where services to patients and clients are rendered. The supervision of technical and support staff and other individuals, including students/interns or trainees, is also dependent upon the context in which the services are provided. This includes federal and state statutes and rules, accreditation standards and facility policies and procedures.
Is direct supervision only needed in hospitals, nursing homes, and rehabilitation facilities and not in community programs, gyms etc. where DTRs may work? Also, how is supervision defined?
When a regulation or standard specifies that the RD is responsible for assessments and patient interventions, it is the expectation that these specific services are performed by that individual. To do otherwise puts the employer, RD and technical support staff at risk of citation and fines, plus potential loss of facility license and certification for payment. This does not preclude technical support staff from interviewing patients, gathering data, conducting screens, and diet and nutritional calculations. The assessment of data collected along with additional information is the responsibility of the registered dietitian. Charting in medical records is also regulated and governed by agencies, accrediting organizations and facility policies and procedures. Therefore, each facility and program is accountable and responsible for ensuring that appropriate charting procedures are followed and that chart entries are accurate, complete and readable.
If the DTR is covered under the RD license, does that mean the RD is responsible for the professional performance of the DTR? Could an RD lose their license if a DTR performs outside of their standards? Does the RD need to cosign or just be available if questions arise?
Licensed healthcare professionals, including physicians, nurses, pharmacists, and others as well as RDs, are accountable and responsible for the quality and safety of care and services they provide, including the services provided by the staff they supervise. Co-signing notes means that you supervised the work that was done and that you agree with the note’s contents.
Is ADA planning to revise the Standards of Practice documents?
ADA is currently reviewing and updating the Standards of Practice in Nutrition Care and Standards of Professional Performance for the RD and DTR. ADA guidance incorporates and considers external factors that impacts the full spectrum of patient and clients services; not the exception which would be dictated by individual business and regulatory entities.
Do these regulations apply to the non credentialed dietetic technician, registered as well?
It is the responsibility of an employer (healthcare facility or program) to define the credentials that qualify staff for various positions beyond those credentials required by federal or state statute or regulation. This does encompass anyone who works under an RD in any technical support role. Both federal and state healthcare facility rules and accreditation standards require that the credentials be verified and documented along with a work history and other personnel requirements to ensure that patients are receiving safe and credible care.

**[i]Note: American Dietetic Association Dietetic Technician Licensure Communications - Q & A - Wednesday, December 20, 2006

Action by ADA’s Board of Directors has focused attention on the roles and responsibilities of our members – whether they are RDs, LDs, DTRs or other nutritionists. In today’s workplace, all of us need to be aware of the regulations and rules particular to our worksites that determine what we as professionals and technicians are recognized to do. For those of us working in healthcare, the requirements have been developed always to protect the public and they are particularly specific. State licensure laws clarify roles and responsibilities but they do not change the relative functions of professionals, technicians and others in allied health.

Roles and responsibilities vary by area of expertise, state, facility, employer, job description and are unique to each individual’s education, training, credentials, skills and competence. ADA cannot provide a single response when members ask specific questions about their scope of practice; what they can do, what they cannot do…ADA advises each and every member to research these questions on their own, and provides guidance in finding the resources they need to use to determine the responsibilities and tasks they are uniquely positioned to do in their own work environment.

For more information on states that have enacted legislation regulating the practice of dietetics, visit www.cdrnet.org/certifications/StateLicensure.htm. View CMS state survey agency contacts at www.cms.hhs.gov/SurveyCertificationGenInfo/Downloads/State_Agency_Contacts.pdf.

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