You Asked About… Clarity on Scope of Practice and Ordering

Aug 21, 2020 | Blog

Dietitians often work in multi-disciplinary workplaces, where communication, both verbal and written, are key aspects of effective and safe practice. Although the word “order” is not part of the Dietitans Regulation, there are workplace contexts where dietitians may be expected to:

  • Write orders directly into the “physician orders” section of the medical record,
  • Write recommendations directly into the “physician orders” section of the medical record, requiring a co-signature from a most responsible physician (MRP) or nurse practitioner (NP),
  • Receive and write an order for dietetic care that is communicated verbally (in person or by another medium).
  • Provide verbal orders or recommendations when practicing remotely.

Note: The Q&A below refer to “verbal orders”, which will be interpreted as verbal in-person or remote via telephone or other virtual media.

Q1: Who is an “authorized prescriber”?

Dietitians are not authorized prescribers. Please refer to: 3.9 Medical Practitioners – Authorized Prescribing – Province of British Columbia (gov.bc.ca) for a list of health professionals authorized to prescribe in BC.

The term “order” is often used interchangeably with the term “prescribe”. For example, the prescribed treatment is often referred to as the “doctor’s order”. Interpretation of the terms “prescribe”, and “order” may vary among health professionals. As a result, confusion may exist amongst healthcare professionals as to who has the authority to prescribe and order.

It is not appropriate for a dietitian to take a verbal order or to request a “co-signature” for an order that requires an authorized prescriber. A dietitian may work with the team to make recommendations that result in an order from an authorized prescriber. Examples can include, but are not limited to, PN orders/changes, removal of a feeding tube, order for a scheduled drug.

Q2: Can I write diet orders or diet recommendations in the physician’s order section of a patient chart?

From a CDBC legal dietetic scope perspective, if the order you are making in the patient’s chart is one that is within your legal and individual scope of practice, you are able to “order” it. In this instance the word “order” means “request” for implementation by the healthcare team. For more information about legal and individual scope of practice, please consult the Decision Tool for New Aspects of Practice.

Parenteral Nutrition (PN) diets require an order (in this instance, the word “order” means prescription) by an authorized prescriber (see Q1). Dietitians who are registered with Restricted Activity B can “design” a patient-specific PN formulation, but cannot legally prescribe it.

In accordance with Standard of Practice 15: “A Dietitian maintains clear and accurate records that document communications and the provision of professional services.” This includes preparing, maintaining, and managing records in compliance with legislative requirements, regulatory policies/guidelines and organizational requirements. The CDBC also recommends that the RD discuss work efficiency issues with his/her interdisciplinary teams and decision makers, keeping in mind that if a documentation or process is preventing a patient from receiving timely nutrition care, it may place the patient at risk.

From a workplace perspective, depending on the facility’s policies and documentation requirements, you may be able to write oral and enteral nutrition diet recommendations in the physician’s orders. The CDBC recommends that you familiarize yourself with workplace ordering and record keeping policies, as part of maintaining clear and accurate records.

According to the Dietitians Regulation, RDs’ scope of practice includes: “…assessment of nutritional needs, design, implementation and evaluation of nutrition care plans and therapeutic diets…”. Implementing a therapeutic diet involves ‘ordering’ a diet.

The Dietitians Regulation states that RDs may ‘dispense’ enteral nutrition, where ‘dispense’ means to fill a prescription for enteral nutrition.

In some instances, however, the workplace ordering system may simply not allow you to record an order. Workplaces where this is the case are listed in section 2 of the BC Residential Care Regulation. Section 67 of the BC Residential Care Regulation requires a physician or nurse practitioner order for enteral nutrition.

Q3: 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?

From a CDBC scope of practice perspective, an oral diet or enteral nutrition change is allowed. As the Dietitians Regulation is written, dietitians do not require an authorized prescriber to order oral and enteral diets. 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.

From a CDBC scope of practice perspective, initial ordering and subsequent orders to change a parenteral diet by dietitians is not allowed as it is not within legal scope of practice. 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 (see Q1).

From a workplace perspective:  Each Health Authority and healthcare facility in BC has the right to narrow 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. A Health Authority/workplace cannot expand dietetic scope of practice beyond the legal limits placed by the Health Professions Act’s Dietitians Regulation.

Q4: Can a nurse implement my diet order?

The Dietitians Regulation permits dietitians to design and order oral and enteral diets without the authority of an authorized prescriber (see Q1). Dietitians are important members of interprofessional healthcare teams and are expected to communicate collegially with other health professionals on their team about new or modified diet orders (Standard of Practice #10).

It may be appropriate for nurses to act on an order from a registered dietitian for an oral diet or enteral diet.

Q5: Can I take a verbal order? What are some considerations?

From a CDBC perspective, a verbal order includes in-person and virtual verbal orders. The Dietitians Regulation is silent about orders, and yet our College recognizes that for emergency situations taking verbal orders for dietetic aspects of care make sense. An example would be a verbal order to modify a tube feeding regimen, which doesn’t involve prescribing drugs. Verbal orders are not a reliable method of care as they increase the risk of omission, 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. In other words, if you are not able to perform the activity yourself, you may not take a verbal order for it. If you receive verbal orders, you should make sure you have clearly understood all components of the order then record and communicate the order clearly and diligently. You should not accept verbal orders that are unclear, incomplete, requiring another health professional’s action, such as an authorized prescriber (see Q1), or unrelated to dietetic services.

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 require an authorized prescriber?
  • 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 workplace 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?
Q6: Can the College come up with a list of actions for which I may write an order or take a verbal order?

It would be impossible for the College to adequately include all instances where taking a verbal 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 order for, if the action being ordered is not within the scope of a dietitian, they may not accept a verbal order for it. In other words, if you are not able to perform the activity yourself, you may not take a verbal order for it, nor may you write a write an order or request a co-signature for it.

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

  • Ordering, changing or discontinuing parenteral nutrition
  • 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 provides registrants some points of consideration for when they are requested to take verbal 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 (see Q1). 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.

Q7: Am I able to order (or take a verbal order) for parenteral nutrition (PN)?

No. The act of writing a prescription is restricted, as it involves a medical diagnosis by a physician, and a 24/7 responsibility to monitor the patient’s tolerance to the prescription as part of their overall medical status, which a dietitian cannot fulfill.

Dietitians who are registered with Restricted Activity B can “design therapeutic diets if nutrition is administered through parenteral means” by completing a patient-specific nutrition assessment and making recommendations for calories, macro- and micronutrients. This does not include signing an order for PN, which is equal to a prescription in this instance. PN is considered a scheduled drug and requires an authorized prescriber to order (see Q1).

While a dietitian can take a verbal order for the “design” portion of the PN, they cannot sign the order as they are not legally authorized to do so. The dietitian cannot sign what constitutes a prescription (as a pre-printed order (PPO) or otherwise) on behalf of an authorized prescriber.

In other words, a dietitian could check off some of the boxes on the PPO and write information relevant to the design of the PN. It cannot be the dietitian’s signature, nor can it be an authorized prescriber’s co-signature. The PPO cannot get implemented without the authorized prescriber’s signature.

 

Q8: Am I able to order (or take a verbal 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 orders. An action, such as removal of an NG tube is NOT an order that dietitians can accept verbally or in writing, because it is not an action that is within dietetic scope of practice. This means that dietitians may also not write an order, nor can they write a recommendation (requesting a co-signature) to remove a naso-enteric tube.

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.

Q9: Am I able to order (or take a verbal order) for blood work (specifically: electrolytes, urea, creatinine, extended electrolytes)?

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 prescriber to recommend the lab tests they require for nutrition assessment and care. Dietitians may not take a verbal order for blood work.

Q10: I work in private practice and appear to be able to register with a laboratory analytical company as a practitioner who can order labs. Can I do this?

As it presently stands, Dietitians are not listed under the LSA and the regulations (Laboratory Services Regulation, sec (3)(1)) as a prescribed referring practitioner. Prescribed health care practitioners have laboratory schedules, as seen in the list of schedules on the for BC’s Agency for Pathology and Laboratory Medicine (PHSA) website. This authority is provided under a ministerial order, signed by the Ministry of Health. In this link, the BC Agency for Pathology and Laboratory Medicine says: “In order for a MSP-enrolled patient to receive laboratory services as a paid benefit, operators of the approved laboratory facilities must receive the request from authorized health care practitioners enrolled under the Medicare Protection Act (MPA). Referring medical practitioners with approved benefit schedules include midwives, nurse practitioners, dentists, podiatrists, and certified registered nurses. These health care practitioners may only request laboratory tests that are defined in their respective scopes of practice.

Dietitians do not currently have the authority to independently order laboratory testing in BC. Until a scope of practice change is approved through the CDBC by the Ministry of Health, the ordering of lab tests might be delegated by medical authority.

If you can register to request lab tests, they need a physician to co-sign the requisition, otherwise, it is not accepted. Because these tests are considered uninsured (non-MSP), they are not bound by the list of authorized referring medical practitioners highlighted above. It is possible that the laboratory analytical company has determined lists of authorized health professionals who can request lab tests (one list for direct requesters, one list for ones who need a physician to co-sign, and one list of people that are not authorized to register and request lab services). These lists are company specific as non-insured service and not prescribed in legislation. 

If you can register to request lab results (with a co-signature) there are additional considerations, that is similar to the way a dietitian would approach nutrigenomic testing (see the Nutrigenomics Q&A for guidance). Specifically:

  1. Understand the definition of dietetics and determine what your individual scope is for recommending specific lab work, using the Decision Tool for New Aspects of Practice (Standards of Practice 2 and 3).
  2. Use evidence-informed information from reputable sources and understand the quality, reliability, and limitations of the tests you are requesting (Standard of Practice 14.5).
  3. Understand the need to explain sample collecting, shipping, analysis and result sharing and data holding to the client. Where are the lab samples shipped for analysis? How and where are the lab samples stored and destroyed? (Standard of Practice 5 and Nutrigenomics Q&A Q4.)
  4. Understand how to explain rationale for lab tests and how to interpret their results in a language level that is appropriate for your client (Standards of Practice 9 and 13 and Nutrigenomics Q&A Q3).
  5. Understand that providing a diagnosis is not part of dietetic scope and dietitians refer clients to a physician for diagnostic lab sharing (Standard of Practice 2.3 and 11).
  6. Understand the need to reflect on the necessity of recommending lab tests, considering the client’s financial situation, and any conflict of interest that may occur or be perceived (Standard of Practice 12 and Nutrigenomics Q&A Q5).
Q11: Are there plans for the profession 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 them as part of their nutrition care plan and write them in the “order section” of the chart, to be processed by nursing professionals and pharmacists. You may find that your workplace has limited 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 (see Q1).

Q12: Can I recommend dosage above the Upper Limit (UL) of a vitamin/mineral supplement?

No. While RDs can recommend vitamins and minerals for oral use to patients as they relate directly to the practice of dietetics, exceptions include supplements for which the active ingredient dosage exceeds those referred to in the Food and Drug Act Drug Schedule and where a prescription from an authorized prescriber is required.

Dietitians are accountable and responsible for the provision of competent, safe, ethical and professional practice. Dietitians should base their clinical recommendations for vitamins on current evidence-based research.

Q13: Can I order a protein or fibre supplement that would go through an enteral tube, or does this require an authorized prescriber?

Most modular products are not considered drugs. Instead, they are classified as “Foods for Special Dietary Use” under the Food and Drug Act. Therefore, these items do not require a prescription and RDs can order them. As per the CDBC Joint Statement on Dietitians’ Authority to Recommend Vitamins and Minerals for Therapeutic Diets an RD can order Schedule 3 (selected from the pharmacy shelf) and Unscheduled Drugs (available outside a pharmacy setting) – “When recommended by a dietitian as part of a therapeutic diet, pharmacists may release Schedule 3 and Unscheduled Drugs and nurses may administer them.” This statement was developed collaboratively between the CDBC, the College of Pharmacists of BC (CPBC), and the colleges that now make up BC College of Nurses and Midwives (BCCNM).

However, there are occasions where modular products may contain ingredients (e.g., high dose vitamins and minerals) that would cause them to be classified as drugs. In such cases, RDs may design an enteral diet with modular products and are currently required to request an authorized prescriber (Q1) to order the diet. The need for an order from an authorized prescriber will depend on how these modular products are classified within the Drug Schedules.

If the products in question are Schedule 3 (selected from the pharmacy shelf) or Unscheduled Drugs (available outside a pharmacy setting), dietitians can order them if they are relevant to a patient-specific nutrition care plan. More information on Drug Schedules Regulation is available on the College of Pharmacists of BC website.

You are encouraged to consult workplace policies to determine the limitations of dietetic scope for ordering enteral nutrition components and formulas.

Q14: 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.

 

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