On August 18, 2005, the CMS released a memo to state survey agency directors that described revisions to the CMS interpretive guidelines for hospitals participating in Medicare Part A.1 This memo was meant to provide clarification to issues related to several CMS standards. One of these standards, [S]482.28 (b)(1), states, "Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of patients." No change in the actual standard occurred, but the interpretive guidelines have been altered as shown on the bottom of this page. The effective date for this change was September 19, 2005.

Dietitians consider themselves to be the "nutrition experts." Many feel they are more capable than other members of the health care team to determine the best possible diet for a patient. They say that physicians only receive a minimal amount of nutrition education so dietitians should determine the most appropriate diet for a patient. These dietitians often point out examples of diet orders they have seen written by physicians that were not appropriate (e.g., regular diets for diabetics, inappropriate tube feedings, regular-consistency diets for edentulous patients, and orders for diets that have not been approved for use in their particular facility).

Recently, many physicians have expressed a genuine interest in nutrition and spent more time learning about it, and understand how the proper diet can positively impact their patients' health. While some physicians may be prone to following the latest fads, others follow sound regimens for themselves and their patients and respect the opinions of dietitians. Physicians also know more about their patients' medical condition, and they often know more than what is documented in patients' charts. Additionally, physicians assess patients first because they admit them and are required to write other orders. Dietitians do not work 24/7, and diet orders need to be in place so patients can eat and drink. If a physician issues an inappropriate order, a dietitian is in the position to discuss it with him or her and have the order changed. How quickly this process takes place depends upon the dietitian involved and the efficiency of communications in the system.

In the real world, we all know that physicians sometimes prescribe diets that are not appropriate. And, although it's hard to admit, we also know that some dietitians recommend or prescribe diets that are not appropriate. There are a variety of reasons for both of these problems including a lack of knowledge, time constraints, and failure to perform a comprehensive assessment.

For the reasons described above, a team approach is the best for the decision-making process. When a dietitian and physician identify and agree on the most appropriate diet for a patient, it really doesn't matter, from the patient's perspective, who writes the order. However, problems arise when the two do not agree, and they are both writing orders. And, from the legal perspective, if a dietitian prescribes a diet that is not appropriate and this causes negative outcomes, a patient can not only bring a lawsuit against the dietitian but against the organization that employs that dietitian as well.

The ADA has provided references for RDs wishing to continue or implement this privilege while still meeting CMS standards at http://www.eatright.org/Member/index_23819.cfm.

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