You Asked About… Scope of Practice and Verbal Orders

Aug 21, 2020 | Blog

Q: Can I take a verbal/telephone order? What are some considerations?

You may be aware that the CDBC recommends limiting verbal orders to emergency or life-threatening situations only. This is because use of verbal orders increases the risk of misinterpretation and error in providing care. In situations where verbal orders are needed and used, it is possible for you to accept verbal orders for issues that are within the scope of dietetic practice. This means that dietitians should only accept verbal orders that they are able to act upon. If you receive verbal orders, you should make sure you have clearly understood all components of the order then document and communicate the order properly and diligently. You should not accept verbal orders that are unclear, incomplete, requiring another health professional action, or unrelated to dietetic services.

Having said that, if you are in a position where you are expected to receive verbal orders, you should consider the following:

  • Is the aspect of practice or task related to my profession and part of my scope of practice?
  • Does it involve restricted activities?
  • Are my personal competencies up to date to do the task safely, ethically, and competently?
  • Does the aspect of practice or task require specific skills?
  • Are there work policies that I need to follow?
  • Are there guidelines or position papers available to guide my practice?
  • Is there scientifically sound literature to support this practice?
  • Do I know who in the inter-professional team needs to be involved to optimize the care and follow-up?
  • Does the client have all the information to make an informed decision and consent?
  • Do I have all the information to make a fair nutritional assessment and recommendation/plan?
  • Am I respecting the client’s needs, values, goals, and circumstances?
  • Is there a potential conflict of interest involved? Do I need to disclose it or recuse myself?
  • Are there any other risks that need to be mitigated?

Q: Can the College come up with a list of actions for which a dietitian may take a verbal or telephone order?

A: It would be impossible for the College to adequately include all instances where a taking a verbal or telephone order may be requested and acceptable of a dietitian. The College’s role is also to establish high level standards and guidelines of practice, and it is the dietitian’s role to apply these in the context of their daily practice. Although there is no policy or guideline that outlines specifically what a dietitian can and cannot accept a verbal/telephone order for, if the action being ordered is not within the scope of a dietitian, he/she may not accept a verbal/telephone order for it. In other words, if you are not able to perform the activity yourself, you may not take a verbal or telephone order for it.

Some recent examples of verbal or telephone orders that the CDBC has had as questions from registrants on, for which dietitians are not allowed to act, include:

  • Removal of naso-enteric tube
  • Ordering bloodwork
  • Ordering a prescription for or changing the dose of a schedule 1 drug
  • Ordering a diet or a vitamin/mineral supplement where the Upper Limit of a nutrient is exceeded (example: 3 g sodium diet)
  • Discontinuation or implementation of intravenous fluids (or the components within them, for example, removal or addition of dextrose in a running IV)

Although this is not a complete list, it will provide registrants some points of consideration for when they are requested to take verbal or telephone orders. For those activities that are not within dietetic scope of practice, but where you may have input, interprofessional collaboration and communication can lead to your recommendations being implemented by an authorized prescriber. These recommendations are a valid and integral part of your nutrition assessment and care plan. If you are unsure whether you can accept a verbal order in a specific situation, you can always reach out to the College to discuss it.

 

Q: Can I take a verbal or telephone order for removal of a naso-enteric tube?

The CDBC reached out to the College of Physicians and Surgeons of BC (CPSBC) to clarify any policies or guidelines that physicians are expected to use when giving verbal and telephone orders. An action, such as removal of an NG tube is NOT an order that dietitians can take verbally or over the phone, because it is not an action that is within dietetic scope of practice.

Neither Restricted Activity A/C (see the Restricted Activity Interpretive Guide) nor the Certification of Insertion of Naso-enteric tubes include the ability of a dietitian to remove an NG tube. Refer to the Restricted Activities page on the website for details.

 

Q: Can I change a diet order written by a physician? If a patient is admitted to hospital and a physician writes an order for a specific diet, am I able to amend the diet order independently?

Example 1. A nephrologist orders a 2g salt restricted diet for renal failure while unaware that the patient also requires a low fibre diet for management of their inflammatory bowel disease. Am I able to add a low fibre restriction?

Example 2. If the physician ordered a lactose-free diet for a patient, but upon RD interview, the patient clarifies that a lactose-free restriction is not required and may restrict variety and intake. Am I able to remove this restriction?

A: The answer is… it depends. There are a few considerations at play here.

From a dietetic scope of practice perspective, a diet change, based on the examples above, is allowed: The definition of “dietetics” includes reference to “the assessment of nutritional needs, design, implementation and evaluation of nutritional care plans and therapeutic diets”. Therapeutic diets involve a wide breadth of options depending on a patient’s medical condition and may involve designing and implementing any oral, enteral (tube feeding) and parenteral diets. As the Dietitians Regulation is written, dietitians do not require an authorized prescriber to order oral and enteral diets. An authorized prescriber is required to order parenteral nutrition (PN) since PN “ingredients” are listed as Schedule 1 drugs (dietitians are not listed as authorized prescribers in BC).

 Interprofessional practice: Although the Dietitians Regulation permits dietitians to order most therapeutic diets without the authority of an authorized prescriber, dietitians remain members of an interprofessional team. As such, dietitians are expected to communicate collegially with other health professionals on their team about new or modified diet orders (Standard of Practice #10).

Nursing scope: It may be appropriate for an NP, RN, RPN or LPN to act on an order from a dietitian for an oral diet or change in an oral diet, provided:

  • The nurse follows BCCNM* (nursing and midwives college) standards for nurses: Acting Within Autonomous Scope of Practice and Acting with Client-specific Orders as well as other applicable standards
  • The organization allows the nurse to act on a client-specific order from a dietitian
  • The nurse follows organization policies and processes for acting on a client-specific order given by a dietitian. Certain sites may not allow nurses to act on client-specific orders from a dietitian and/or requires nurses to obtain a client-specific order from a physician or nurse practitioner for all oral diets. In this situation, the nurses would not be allowed to act on an order given by a dietitian since they are required to follow organizational policies and processes.
  • The nurse is competent and safe to accept the order. Additionally, the scope of practice for LPNs is focused on clients who are stable or predictable. The CDBC has reached out to the BCCNP (soon to be the BCCNM) and has been informed that they are in the process of clarifying their policies and guidelines, including their definition of “authorized prescribers” for diet orders.

Facility/Health Authority limitation: While the Dietitians Regulation permits Dietitians to design and implement (request) any kind of therapeutic diet without an authorized prescriber’s order (except for PN), each Health Authority and healthcare facility in BC has the right to narrow this scope of practice and establish polices and procedures that work best for their delivery of care.  You should be aware of your workplace scope restrictions by reviewing workplace policies and guidelines.

* The BC College of Nursing Professionals will be renamed the BC College of Nurses and Midwives on September 1, 2020, following amalgamation with the College of Midwives of BC.

 

Q: Are dietitians allowed to order blood work (specifically: electrolytes, urea, creatinine, extended electrolytes)?

A: Dietitians are not on the list of health professionals authorized to order lab tests in British Columbia. This list is found in section 3 of the Laboratory Services Regulation. Dietitians may work in collaboration with an authorized professional (MD, Nurse Practitioners or Registered Nurses) to recommend the lab tests they require for nutrition assessment and care.

 

Q: Are there plans for dietitians to be able to order single nutrient vitamins, such as thiamine (po and/or IV)?

Please refer to the Joint Statement on Dietitian’s Authority to Recommend Vitamins and Minerals. In it, you’ll find that the CDBC worked with nursing and pharmacy colleges to gain recognition of dietitians’ authority to order unscheduled and Schedule 3 vitamins and minerals for use in oral and enteral diets. As these products do not require a prescription, it is within the dietitian’s scope to include it as part of their nutrition care plan and write it in the “order section” of the chart, so it can processed by nursing professionals and pharmacists. You may find that your workplace has constrained dietitians’ scope, so if you are not able to order these in your workplace, it may be due to a limitation in workplace policy.

Further, IV preparations are Schedule 1 of the BC Drug Schedules, so they are not within scope for a dietitian to order and rather, require an authorized prescriber (e.g., physician, nurse practitioner) order.

 

Q: How do I determine if I can recommend a certain medication/drug to a patient? The Joint Statement on Dietitians’ Ability to Recommend Vitamins and Minerals talks about schedule 3 and unscheduled drugs being within scope for a dietitian. How do I find the classification of drugs?

The CDBC recently reached out to the College of Pharmacists of BC (CPBC) for this exact question.

When trying to determine scheduling, not everything is listed in BC Drug Schedules Regulation. Normally, this regulation includes drugs that have a stricter classification than federal regulation. For that reason, the best order of search is as follows:

  1. Health Canada Drug Product Database (DPD)
  2. BC Drug Schedules Regulation
  3. National Association of Pharmacy Regulatory Associations (NAPRA) – BC does not fully adopt NAPRA scheduling, but it remains a good guide for products that cannot be found in the federal or provincial schedules

Interestingly, the CPBC commented on dietitians’ ability to perform Insulin Dose Adjustments (IDA) with a consideration that could impact clients. Making dose adjustments to insulin becomes quite involved with respect to Pharmacare billing and third-party coverage. Dietitians, like pharmacists, do not have independent prescribing authority. As a result, third-party payors may only cover products with a receipt written by an authorized prescriber. Dietitians may want to discuss this aspect with their patients when they address insulin dose adjustment as part of nutrition counseling.

 

Recent Posts