I am a Dietary Service Supervisor in California. Can you tell me who is authorized to sign what in an in-house patient’s chart?
There always seems to be the question here as to which of my charting assignments needs to be co-signed by a registered dietitian. I write physician suggested diet changes; I perform all assessments and basically do all of the necessary chartings for our Dietary Department. Where can I find the necessary guidelines? Thanks.
Would you like me to post your question to a dietitian’s electronic mailing list (EML)? If yes, please reply. Perhaps a consulting dietitian could provide you with the current regulations in your healthcare facility.
Generally, it would be a Registered Dietitian who would write patient notes in the medical record. However , it varies with each facility’s medical director, but there are also JCAH (Joint Committee on the Accreditation of Hospitals) regulations that cover medical record documentation.