BY ORDER OF THE SECRETARY OF THE AIR FORCE AIR FORCE

BY ORDER OF THE

SECRETARY OF THE AIR FORCE

AIR FORCE MANUAL 44-144

20 JANUARY 2016

Medical Operations

NUTRITIONAL MEDICINE

COMPLIANCE WITH THIS PUBLICATION IS MANDATORY

ACCESSIBILITY:

Publications and forms are available for on the e-Publishing website at

www.e-Publishing.af.mil for downloading or ordering.

RELEASABILITY:

There are no releasability restrictions on this publication.

OPR: 559 MDG/CC

Supersedes: AFMAN44-144, 29 June 2011

Certified by: AF/SG3/5

(Maj Gen Roosevelt Allen)

Pages: 86

This Manual provides guidance for provision of nutrition education, medical nutrition therapy

(MNT), consultant services and management of manpower, subsistence, equipment, and

expendable supply resources in Nutritional Medicine (NM) operations in Air Force Medical

Treatment Facilities (MTF). This manual implements DODI 1338.10-M, Manual for the

Department of Defense Food Service Program, DODI 6025.24, Provision of Food and

Beverages to Certain Members and Dependents Not Receiving Inpatient Care in Medical

Treatment Facilities (MTFs), DODI 6130.50, DoD Nutrition Committee, and AFPD 44-1,

Medical Operations, and interfaces with AFPD 40-1, Health Promotion; AFI 40-101, Health

Promotion; AFI 40-104, Health Promotion Nutrition; AFI 41-120, Medical Resource

Management Operations. This Manual does not apply to the Air Force Reserve, except where

noted. This Manual does not apply to the Air National Guard. Send comments and suggested

improvements on AF Form 847, Recommendations for Change of Publication, through major

commands to the Air Force Surgeon General, HQ USAF/AFMSA, 7700 Arlington Blvd., Falls

Church, VA 22042-5158. Ensure that all records created as a result of processes prescribed in

this publication are maintained IAW Air Force Manual (AFMAN) 33-363, Management of

Records, and disposed of IAW Air Force Records Information Management System (AFRIMS)

Records Disposition Schedule (RDS). The authorities to waive wing/unit level requirements in

this publication are identified with a Tier (“T-0, T-1, T-2 or T-3”) number following the

compliance statement. See AFI 33-360, Publications and Forms Management, for a description

of the authorities associated with the Tier numbers. Submit requests for waivers through the

chain of command to the appropriate Tier waiver approval authority, or alternately, to the

Publication OPR for non-tiered compliance items. The use of the name or mark of any specific

manufacturer, commercial product, commodity, or service in this publication does not imply

endorsement by the Air Force.

2 AFMAN44-144 20 JANUARY 2016

SUMMARY OF CHANGES

This publication reflects significant changes in guidance and procedures in Nutritional Medicine

operations. Substantially revised, this document must be reviewed in its entirety. Major changes

include: added financial management billing error procedures, updated meal rates and meal day

values, the Joint Culinary Center for Excellence Quartermaster Basic Daily Food Allowance

(BDFA) calculation, Wounded Warrior meal reference guidance, and new DoDI 6025.24,,

Provision of Food and Beverages to Certain Members and Dependents Not Receiving Inpatient

Care in Medical Treatment Facilities, guidance. Additional changes include the removal of the

table of contents, updated mission statement, and removal of references to Health and Wellness

Centers. Chapter 2 was added detailing the roles and responsibilities of authority levels.

Nutrition in Prevention course attendance was removed and compliance with AFI 36-807,

Weekly and Daily Scheduling of Work and Holiday Observances was included. Nutrition

screening and outpatient therapeutic diet procedures were updated and Privacy Act requirements

were incorporated into inpatient meal service procedures. An attachment was added to the

chapter on subsistence account reporting and management as a compliance checklist for

purchasing, storing, inventorying, issuing, cost control, pricing, cashier operations, and ration

accounting. All chapters were updated per subject matter expert recommendations. The

document was also tiered in accordance with AFI 33-360.

Chapter 1—MISSION, VISION, AND ORGANIZATION 5

1.1. Mission and Vision. ............................................................................................... 5

1.2. Organization. .......................................................................................................... 5

Chapter 2—ROLES AND RESPONSIBILITIES 6

2.1. Air Force Surgeon General (AF/SG) shall: ............................................................ 6

2.2. Air Force Deputy Chief of Staff for Manpower and Personnel (AF/A1) shall: ..... 6

2.3. AF/SG Dietetics Consultant shall: ......................................................................... 6

2.4. Career Field Manager shall: ................................................................................... 6

2.5. Major Command (MAJCOM) Dietitian shall: ....................................................... 6

2.6. Medical Group Commander (MDG/CC) shall: ..................................................... 6

Chapter 3—PLANNING AND EVALUATION 8

3.1. NM Organizational Strategy. ................................................................................. 8

3.2. Performance Improvement (PI). ............................................................................ 8

3.3. Disaster and Contingency Planning. ...................................................................... 9

3.4. Menu Planning. ...................................................................................................... 9

Chapter 4—PERSONNEL ADMINISTRATION 11

4.1. Staffing, Utilization and Job Titles. ....................................................................... 11

Table 4.1. NM Officer Staffing and Duty Titles. .................................................................... 11

AFMAN44-144 20 JANUARY 2016 3

4.2. Duties. .................................................................................................................... 11

4.3. Job Descriptions. .................................................................................................... 12

4.4. Competency Assessment. ...................................................................................... 12

4.5. Work Schedules and Daily Assignments. .............................................................. 14

4.6. Education and Training. ......................................................................................... 14

4.7. Workload Reporting. ............................................................................................. 15

Chapter 5—NUTRITION CARE 18

5.1. Medical Nutrition Therapy (MNT). ....................................................................... 18

5.2. Patient Rights and Privacy. .................................................................................... 21

5.3. Nutrition Screening. ............................................................................................... 21

5.4. Documentation and Peer Review. .......................................................................... 22

5.5. Ordering Inpatient Meals and Nourishments. ........................................................ 23

5.6. Inpatient Meal Service ........................................................................................... 25

5.7. Dietary Kardex (AF Form 1741) or Electronic/MTF-Equivalent. ......................... 25

5.8. Meal Hours ............................................................................................................ 26

5.9. Bedside Tray Service. ............................................................................................ 26

5.10. Enteral Nutrition, Medical Foods, and Infant Formulas. ....................................... 27

5.11. Parenteral Nutrition (TPN, PPN). .......................................................................... 28

5.12. Therapeutic Diets for Outpatients. ......................................................................... 28

5.13. Patient and Family Education. ............................................................................... 28

5.14. Health Promotion Nutrition. .................................................................................. 29

Chapter 6—FOOD PRODUCTION AND SERVICE 30

6.1. Production Planning. .............................................................................................. 30

6.2. Purchasing Non-Food Supplies. ............................................................................. 31

6.3. Food Portion and Waste Control. ........................................................................... 31

6.4. Hazard Analysis and Critical Control Point (HACCP) .......................................... 32

6.5. Sanitation and Infection Control. ........................................................................... 33

6.6. Patient Tray Assembly. .......................................................................................... 33

Chapter 7—FINANCIAL MANAGEMENT 34

7.1. Budgets. ................................................................................................................. 34

7.2. Prime Vendor. ........................................................................................................ 34

7.3. Financial Accountability. ....................................................................................... 35

4 AFMAN44-144 20 JANUARY 2016

7.4. Subsistence Purchasing. ......................................................................................... 35

7.5. Unauthorized Uses of Subsistence Items. .............................................................. 37

7.6. Perpetual Inventory. ............................................................................................... 37

7.7. Physical Inventory. ................................................................................................ 37

7.8. Closing a NM Activity. .......................................................................................... 39

7.9. Issuing Subsistence. ............................................................................................... 39

7.10. Costing Subsistence Items. .................................................................................... 40

7.11. Excess Cost. ........................................................................................................... 40

7.12. Cashier Operations. ................................................................................................ 40

7.13. Eligibility and Identification of Diners. ................................................................. 43

7.14. ALACS Recipe Pricing Operations. ...................................................................... 45

7.15. Special Feeding Circumstances. ............................................................................ 46

7.16. NM Ration Accounting. ......................................................................................... 46

7.17. Subsistence Account Reporting and Management. ................................................ 48

Chapter 8—PROCEDURES FOR MEDICAL FACILITIES SUPPORTED BY BASE

FOOD SERVICE AND DIETETIC SHARING AGREEMENTS 51

8.1. Procedures for MTFs supported by Base Food Service. ........................................ 51

8.2. Dietetic Sharing Agreements. ................................................................................ 52

Chapter 9—CONSULTANT SERVICES 54

9.1. Purpose. .................................................................................................................. 54

9.2. The Consultant Dietitian. ....................................................................................... 54

9.3. Enlisted Consultant Roles. ..................................................................................... 57

9.4. NM Dietitian or Diet Therapy Personnel. .............................................................. 59

Attachment 1—GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION 60

Attachment 2—4D0X1 DIET TECH DIET COUNSELING AUTHORIZATION GUIDE 71

Attachment 3—PERSONS AUTHORIZED TO EAT IN MILITARY TREATMENT

FACILITY DINING FACILITIES 75

Attachment 4—TABLE A4.1. NUTRITIONAL MEDICINE SUBSISTENCE REPORT

(EXCEL SPREADSHEET). 78

Attachment 5—SAMPLE MOA BETWEEN NM & BASE FOOD SERVICE 79

Attachment 6—NUTRITIONAL MEDICINE SERVICE OVERSIGHT CHECKLIST 82

AFMAN44-144 20 JANUARY 2016 5

Chapter 1

MISSION, VISION, AND ORGANIZATION

1.1. Mission and Vision. The mission of NM is to optimize health and performance through

nutrition. The NM vision is to be the global leaders in nutrition, fueling performance.

1.2. Organization. If a separate NM Element/Flight is feasible, then all NM personnel are

assigned to the NM unit under Functional Account Code (FAC) 5520 and matrixed to Health

Promotion as appropriate to complete health promotion nutrition interventions and provide MNT

when indicated. In clinics, the Medical Treatment Facility (MTF) Commander decides the best

location in the organization for NM personnel. Regardless of location, NM clinics with an

assigned Registered Dietitian/Registered Dietitian Nutritionist (RD/RDN) will simultaneously

provide health promotion nutrition education programs, as well as complete referrals for MNT

IAW AFI 44-102, Medical Care Management (T-2). Organizational structure for NM flights and

elements is more fully described in Chapter 3, Personnel Administration.

1.2.1. In Air Force Reserve Command (AFRC) units, NM personnel may be assigned to the

Medical Squadron or Aeromedical Staging Squadron (ASTS) where they may provide

nutrition education programs and support the Air Force Fitness Program. AFRC NM

personnel are also assigned to active duty NM units.

6 AFMAN44-144 20 JANUARY 2016

Chapter 2

ROLES AND RESPONSIBILITIES

2.1. Air Force Surgeon General (AF/SG) shall:

2.1.1. Ensure adequate programming, budget, training, and research to support nutritional

medicine.

2.1.2. Advocate for comprehensive and evidenced-based strategies to create a culture and

environment supportive of nutritional medicine.

2.1.3. Collaborate and coordinate nutrition policy with US Air Force Deputy Chief of Staff

for Manpower and Personnel (AF/A1).

2.2. Air Force Deputy Chief of Staff for Manpower and Personnel (AF/A1) shall:

2.2.1. Support AF/SG in developing Air Force nutrition policy.

2.2.2. Provide policy and guidance for integrating and vetting new/emerging institutional

education and training requirements or learning outcomes into accessions, Professional

Military Education (PME), Professional Continuing Education (PCE) and ancillary training.

2.3. AF/SG Dietetics Consultant shall:

2.3.1. Advise AF/SG on nutrition policy.

2.3.2. Coordinate with Air Force Medical Operations Agency (AFMOA) Health Promotion,

Air Force Medical Support Agency (AFMSA) Health Promotion, and Air Force Medical

Operations Agency/Biomedical Sciences Corps (AFMOA/SGB) on nutritional guidance and

programs.

2.4. Career Field Manager shall:

2.4.1. Advise AF/SG Dietetics Consultant on enlisted force matters.

2.4.2. Ensure career progression is being conducted across the career field.

2.5. Major Command (MAJCOM) Dietitian shall:

2.5.1. Coordinate with HP RDs on training, peer review, and mentorship on medical

nutrition therapy.

2.5.2. Advise the command and appropriate higher headquarters staff on nutrition issues, and

provide guidance and nutrition consultation to bases and MTFs.

2.5.3. Serve as clinical supervisor for HP RDs to include the credentialing process and diet

certification.

2.5.4. Direct the peer review process for nutritional medicine.

2.6. Medical Group Commander (MDG/CC) shall:

2.6.1. Advocate for comprehensive, evidence-based strategies to create a culture and

environment supportive of nutritional medicine (T-3).

AFMAN44-144 20 JANUARY 2016 7

2.6.2. Provide adequate programming, budget, training, and resourcing to achieve nutritional

medicine goals and objectives. (T-3).

2.6.3. In collaboration with the MAJCOM Dietitian, provide options to ensure all patients

have access to nutrition education. (T-3).

8 AFMAN44-144 20 JANUARY 2016

Chapter 3

PLANNING AND EVALUATION

3.1. NM Organizational Strategy. The purpose of long and short term strategy is to ensure

NM operations and associated activities are aligned with the Air Force Medical Service (AFMS)

strategy map. Individual NM organizational strategies should also be aligned with current,

overall strategic plans for the career field. Management strategies provide the NM flight an

opportunity to establish instruction and policies that focus and allocate NM resources. Strategies

should encompass both NM operations as well as efforts to make improvements. Strategic

planning sessions will include representation from airmen, civilians, contractors, NCOs, and

senior NM leaders. (T-3). The NM Organizational Strategy should be consistent with the MTF

Strategic Plan, and outline management objectives, improvement efforts, and resources. Each

NM flight should maintain a department strategic plan which includes a mission statement and

organizational chart, and goals/ objectives/action plans. (T-3)

3.1.1. Continuous communication with NM personnel and MTF senior leaders should take

place throughout the planning process and implementation of the NM action plans.

3.2. Performance Improvement (PI). Performance Improvement is a continuous activity that

involves measuring the function of important processes and services and when indicated,

identifies changes that enhance performance. These changes are incorporated into new and

existing processes, products, or services and are monitored to ensure improvements are

sustained. PI focuses on clinical, administrative and cost-of-care issues as well as patient

outcomes (results of care). The fundamental components of PI include staff education,

measuring performance through data collection, assessing current performance, utilizing the data

collected to improve organizational processes, services, and overall performance and re-

education. PI includes evaluating the following attributes: efficacy, appropriateness, availability,

timeliness, effectiveness, continuity, safety, efficiency, respect, and care. Performance measures

should focus on critical processes in nutrition care, food production and management of

personnel and financial resources. In addition, peer review is conducted and submitted in

accordance with local credentialing authority guidance to the appropriate MAJCOM Dietitian.

(T-3).

3.2.1. PI activities, based on facility scope of practice and capability, are focused on high-

risk, problem prone, high volume and high cost areas but are not limited to those areas.

3.2.1.1. Examples of high-risk patient process include: patient tray food temperatures,

NPO/clear liquid tracking, nutrient-drug interaction counseling documentation, inpatient

screening timeframes, and patient tray and menu accuracy.

3.2.1.2. Examples of problem prone processes include: nutrition clinic no-show rates,

kardex accuracy, absenteeism per time period, and number of work injuries per hours

worked.

3.2.1.3. Examples of high volume and high cost areas include: outcomes of MNT for

management of hyperlipidemia, diabetes, and weight control, cost per dining facility

meal, cost per patient meal, and cost per unit.

AFMAN44-144 20 JANUARY 2016 9

3.2.2. NM will have Performance Improvement Teams consisting of a team leader,

facilitator, recorder and team members as appropriate. Meeting minutes will be recorded and

maintained. (T-3).

3.3. Disaster and Contingency Planning. NM with in-patient feeding capabilities must have a

plan that establishes responsibilities and basic procedures for feeding patients and staff during

both wartime and peacetime contingency and disaster operations. (T-1). This plan is an annex in

the MTF's Medical Contingency Response Plan (MCRP).

3.4. Menu Planning. The Flight Commander/Element Chief is responsible for planning the

regular selective cycle and any special menus for the hospital to which they are assigned. (T-3).

The Chief, Clinical Dietetics is responsible for writing the therapeutic menus. All regular and

therapeutic menus will be approved by the NM Flight Commander/Element Chief. (T-3). At

hospitals with no dietitian assigned, regular and therapeutic menus will be written by the

NCOIC, NM and approved by the MAJCOM Dietitian. (T-3).

3.4.1. Cycle Menu Planning. Menu planning considerations should include subsistence

ordering and delivery schedules, subsistence storage capacity, available equipment,

subsistence budget, subsistence seasonal availability, personnel skills and abilities, seasonal

and religious holidays, patron preferences, average inpatient length of stay, disease

prevalence of patient population, patient age group considerations, cultural nutritional needs,

type of inpatient food service operation and facility menu style (room service, a la carte,

electronic menus, etc.).

3.4.1.1. All menus are designed to achieve or maintain optimal nutritional status. To the

greatest extent possible, regular/general menus will adhere to the Joint Subsistence Policy

Board, Department of Defense menu standards, which promote the United States

Department of Agriculture (USDA), and Department of Health and Human Service

(DHHS) Dietary Guidelines for Americans. (T-0). Therapeutic menus will follow

current recommendations for the MNT treatment of such acute and chronic disease states.

Consult the AND Nutrition Care Manual (NCM), Pediatric Nutrition Care Manual

(PNCM), Sports Nutrition Care Manual (SNCM), Dietary Guidelines for Americans, the

USDA Food and Nutrition Service’s Menu Magic for Children and/or other professional

sources for additional information on planning healthy menus.

3.4.1.2. Evaluate all menus for nutritional adequacy. (T-3). At a minimum, assess

compliance to Joint Subsistence Policy Board, Department of Defense Menu Standards

and compare nutrient content to the USDA MyPlate suggested servings for each food

group. Computrition and/or other commercial nutrient analysis programs may be used

for more detailed nutritional analysis as needed.

3.4.1.3. Develop the therapeutic cycle menu using items from the regular menu and in

the same sequence, as much as possible. (T-3). The content of the various therapeutic

diets are a function of and defined by the literature contained within the NCM.

3.4.1.4. Establish the type of inpatient food service operation as appropriate for the

facility. (T-3). Examples may include but are not limited to non-select menus, select

menus, buffet-style selection, hotel or room service, or any combination. Create a

hospital master menu in a format most appropriate to easily transfer to the style of menu

10 AFMAN44-144 20 JANUARY 2016

for the facility, i.e., AF Forms 1737 or 1739, Selective Menu, Hotel/Room Service menu,

Computrition, etc. (T-3). Reproduce menus as necessary.

3.4.1.5. Develop standard daily/weekly rotations for nutritional supplements and

food/snack items, as necessary, to ensure appropriate variety. (T-3).

3.4.1.6. At a minimum, update and modify menus annually. (T-3).

3.4.1.7. Develop a patient/customer feedback process to evaluate patient satisfaction

with menu items and NM service. (T-3). Results of patient satisfaction surveys and

customer feedback can be valuable when updating and modifying menus and food

production and service processes.

AFMAN44-144 20 JANUARY 2016 11

Chapter 4

PERSONNEL ADMINISTRATION

4.1. Staffing, Utilization and Job Titles. NM Flight Commander/Element Chief is the senior

dietitian (AFSC 43D3) assigned. In facilities where more than one dietitian is assigned, use

Table 4.1 to determine duty titles and functions.

Table 4.1. NM Officer Staffing and Duty Titles.

Number of Dietitians

Assigned

NM Flight

Commander/Element

Chief

Clinical Dietetics

Element/Section

Chief

Clinical Dietitian

3 or more

1 or more

4.1.1. With the exception of organizations that support the AF SG Consultant

Dietitian/Biomedical Science Corps (BSC) Associate Chief for Dietetics or those supporting

the US Military Dietetic Internship Consortium and Graduate Program in Nutrition (GPN),

all RDs, other than the squadron or flight commander, will be assigned to patient care or

health promotion positions. Nutritional Medicine officer duty titles not listed above should

be approved by the AF SG Consultant Dietitian/BSC Associate Chief for Dietetics. In MTFs

where no dietitian is assigned, the MTF Commander designates an officer, not subject to

conflict of interest, as the NM Element Chief. (T-3).

4.1.2. The NM Manager/Superintendent/NCOIC is the most senior Diet Therapist (4D0X1).

Duty for enlisted personnel will conform to the standardized job and duty title guidance as

described in AFI 36-2618, The Enlisted Force Structure, and AFI 36-2201, Air Force

Training Program. (T-1). Exceptions must be approved by the Career Field Manager (CFM).

4.1.3. Considering the Unit Manpower Document (UMD), the Unit Personnel Management

Roster (UMPR), and the NM Product Line Analysis, a staffing plan must be developed and

available in each section to ensure an adequate number of personnel are assigned. (T-3).

4.2. Duties.

4.2.1. The NM Flight Commander/Element Chief is responsible for the planning,

organization, management, operation, performance improvement and coordination of NM

Flight/Element activities which include meal service to patients and authorized diners,

clinical nutrition and participation in health promotion programs. (T-3). The Flight

Commander/Element Chief also directs food procurement, production and service including

the planning, preparation and service of regular and therapeutic diets for MTF patients,

aeromedical evacuation patients, hospital personnel and dining facility patrons within

financial limitations; directs education activities including career development of dietitians

and proficiency development of NM personnel; oversees inpatient and outpatient clinical

dietetics activities including provision of MNT and community nutrition education. In NM

12 AFMAN44-144 20 JANUARY 2016

with one dietitian, the NM Element Chief has direct responsibility for food production and

service, along with providing clinical dietetics support by supervising and performing MNT

and nutrition education. (T-3).

4.2.2. Diet Therapy Superintendent/Chief Enlisted Manager (CEM) oversees the operation

of NM flight activities, plans and organizes nutrition care activities, directs food service

activities, inspects and evaluates nutrition care activities, performs technical nutrition care

functions, and plans and organizes nutrition care activities. (T-3). Consult the Career Field

Education and Training Plan (CFETP) 4D0X1 for more specific descriptions of duties for

diet therapy personnel assigned.

4.3. Job Descriptions. Job descriptions, including qualifications, responsibilities, and written

performance standards must be available for each duty position IAW AFI 44-119. (T-3).

4.4. Competency Assessment. The NM Flight Commander/Element Chief will ensure that

policies, procedural guidelines and national care standards are followed IAW AFI 44-119. (T-3).

4.4.1. Dietitian Credentialing and Privileging. RD competency is documented through the

credentialing and privileging process. Active duty, reserve, civilian, contract, and any

volunteer dietitians will be credentialed and awarded MTF clinical privileges IAW AFI 44-

119 before providing care to patients. (T-1). IAW AF Form 3930, Clinical Privileges-

Dietetics Providers, or the electronic equivalent form in Centralized Credentials Quality

Assurance System (CCQAS); an applicant’s ability to provide patient services within the

scope of clinical privileges requested will be based upon the following minimum criteria:

written verification of completion of a minimum of a baccalaureate degree from an

accredited college or university and completion of an AND-approved didactic program in

dietetics; written verification of successful completion of an AND-accredited supervised

practice program (Dietetic Internship OR Coordinated Program in Dietetics); written

verification of current registration by the AND OR written proof of eligibility to take the

AND registration examination. (T-0). Direct accession service members must obtain

registration prior to entry on active duty. Graduates of the US Military Dietetic Internship

Consortium/GPN must obtain registration within four months of graduation. (T-2). Once

dietitians achieve basic/core credentials and privileges, they should maintain currency and

competencies sufficient to support readiness/deployment missions.

4.4.1.1. Specialized board certifications are encouraged, but are not mandatory, for all

dietitians. RDs may be eligible for the following recognized board certifications:

Certified Nutrition Support Clinician (CNSC), Certified Diabetes Educator (CDE),

Certified Health Education Specialist (CHES), Registered Clinical Exercise Physiologist

(RCEP), Registered Exercise Specialist (RES), and the following AND certifications:

Certified Specialist in Gerontological Nutrition (CSG), Certified Specialist in Sports

Dietetics (CSSD), Certified Specialist in Pediatric Nutrition (CSP), Certified Specialist in

Renal Nutrition (CSR), and Certified Specialist in Oncology Nutrition (CSO) the Fellow

of American Nutrition and Dietetics (FAND). Many board certifications are eligible for

Non-Physician Health Care Provider Board Certified Pay. Some specialized positions

within the AFMS may require board certification, and board certified CNSC and CDE

dietitians may receive additional clinical privileges. In addition, advanced privileges may

be granted by the institution-specific privileging body.

AFMAN44-144 20 JANUARY 2016 13

4.4.1.1.1. Additional clinical privileges for CNSC dietitians may include: ordering

enteral feedings, including type of formula, rate, strength, type/size of feeding tube,

gastrointestinal location of feeding tube and evaluation of tolerance; total and

peripheral parenteral nutrition (TPN & PPN), including macronutrients, rate, volume,

additives and cycling schedule; transitional feedings; blood glucose checks for cyclic

TPN; and 24 hour urine collections for nitrogen balance studies.

4.4.1.1.2. Additional clinical privileges for CDE dietitians include: practicing as a

case manager; regulating insulin; and, educating patients on the use of a glucometer.

4.4.1.1.3. When privileged to perform as a CNSC or CDE, the individual will meet

the following criteria: provide written verification of initial certification from the

granting agency, show evidence of meeting continuing education requirements in the

respective specialty and provide evidence of completion of recertification

requirements as mandated by the granting agency. (T-0).

4.4.1.1.4. Dietitians may have more advanced privileges; such as, performing

indirect calorimetry, ordering dual energy X-Ray Absorptiometry (DXA), or

performing advanced nutrition focused physical exam. The dietitian will provide

written verification of training or education supporting the privilege being requested.

(T-3).

4.4.1.2. Recommendation for reappointment of privileges will be based upon the

following criteria: maintaining registration status as a RD, active practice of dietetics,

evidence of demonstrated proficiency based upon quarterly peer reviews that show no

negative trends nor validated occurrences that would warrant privilege limitations,

current Basic Life Support (BLS) training and evidence of completion of required

Continuing Education Units (CEU). (T-0).

4.4.2. Diet Therapy Personnel Competency. Diet therapy personnel competency is assessed

initially for everyone within the first 60 days of assignment to determine proficiency level.

(T-3). This may be demonstrated through attendance at formal military diet therapy courses,

nationally accredited certifications, enlisted specialty training and assessment/authorization

of diet therapy skills by a RD.

4.4.2.1. The NM Manager/Superintendent, and NCOIC must obtain and maintain the

skill level commensurate with their grade and attend Professional Military Education

appropriate for their grade. (T-3). Diet Therapy Craftsmen (active duty or reserve)

should attend our Nutrition Management Accounting Course as soon as possible once

assigned to a MTF. (T-3).

4.4.2.2. Diet Authorizations. Credentialed RDs use AF Form 628, Diet

Instruction/Assessment Authorization, to evaluate and authorize diet therapists for:

nutrition screenings, nutrition assessments, nutrition progress notes, and individual,

group, or family education. (T-2). See Attachment 2, Diet Counseling Authorization

Guide, for a list of approved diet authorizations. Exceptions to Attachment 2 must be

approved by the MAJCOM Dietitian. Diet authorizations may be valid for up to two

years. When significant changes in diet instruction materials or nutrition practice occur

within the two-year period, a RD must accomplish reauthorization. (T-2). The leader of

the MNT Work Group will inform the AF SG Consultant Dietitian/BSC Associate Chief

14 AFMAN44-144 20 JANUARY 2016

for Dietetics when significant changes occur that warrant reauthorization of diet

technicians. (T-1). In turn, the AF SG Consultant Dietitian/BSC Associate Chief for

Dietetics will inform the MAJCOM Dietitians. (T-3).

4.4.2.3. Dietary Manager’s Association (DMA), Certified Dietary Manager (CDM), and

Certified Food Protection Professional (CFPP) certifications, and Diet Technician

earn the above mentioned certifications will also be taken into consideration for advanced

enlisted leadership positions through the annual Diet Therapy Enlisted Development

evaluation board.

4.5. Work Schedules and Daily Assignments.

4.5.1. NM work schedules will comply with AFI 36-807, Weekly and Daily Scheduling of

Work and Holiday Observances.

4.6. Education and Training.

4.6.1. Orientation. Employee Orientation will be performed and documented for each new

military, civilian, and contract employee within the first 30 days of employment IAW AFI,

44-119, Medical Quality Operations. (T-0).

4.6.2. Age-specific training. Age-specific training focuses on the ages of patients/clients

served and includes the ability to obtain and interpret information in terms of patient needs,

knowledge, growth and development as well as range of treatment options. This training

must be provided before staff may work with specialized age groups, and must be repeated

annually. (T-3).

4.6.3. In-Service Training.

4.6.3.1. Base recurring in-service training on required annual training, type and nature of

services provided, individual NM needs, information from performance improvement

activities, infection control activities, safety program, performance appraisals and peer

review.

4.6.3.2. Establish and document an annual in-service training schedule. (T-3).

4.6.3.2.1. Record date training was conducted, learning objectives, detailed topic

outline, names of attendees at initial and make up sessions and the instructor. (T-3).

4.6.3.2.2. Establish a method of training for personnel not in attendance at the initial

session to ensure all personnel receive training. (T-3).

4.6.3.3. A dietitian or NCO will ensure the effectiveness of preparation, presentations,

and documentation of each session. (T-3).

4.6.3.3.1. Evaluate in-service training using written post-quizzes, skill demonstration,

group discussion or other evaluation methods. (T-3).

4.6.3.4. At a minimum, the following training must be provided on an annual basis,

unless otherwise noted.

4.6.3.4.1. Fire Safety. Develop a Job Safety Training Outline that identifies and

addresses section specific safety hazards IAW AFI 91-301, Air Force Occupational

AFMAN44-144 20 JANUARY 2016 15

Safety, Fire Protection and Health Program. Documented on AF Form 55, Employee

Safety and Health Record. (T-3).

4.6.3.4.2. Federal Hazard Communication Training and Workplace Specific Hazard

Communication Training (HAZMAT). Handling of hazardous materials is also

briefed on employees’ initial and annual Occupational Safety and Health

Administration (OSHA) training. The job specific training will be given individually

and in small groups by authorized trainers. (T-0). Documented on AF Form 55.

4.6.3.4.3. Disaster Preparedness/MCRP. The NM Team Chief, IAW AFI 41-106,

Unit Level Management of Medical Readiness Programs, is responsible to develop

the MCRP team annual training plan that ensures each team member receives annual

and make-up training to maintain proficiency standards and ensure training is

documented in Medical Readiness Decision Support System (MRDSS) ULTRA. (T-

3).

4.6.3.4.4. Readiness Skills Verification (RSV). The AFSC functional training

managers at the unit level, IAW AFI 41-106, are responsible for developing the

annual RSV training plan for their AFSC, complete annual gap-analysis, ensure RSV

and make-up training are conducted using standardized career field materials and

documented in MRDSS ULTRA. (T-3).

4.6.3.4.5. Anti-Robbery/Resource Protection. (T-3).

4.6.3.4.6. Food Handlers Training IAW AFI 48-116, Food Safety Program and the

AFMAN 48-147_IP, Tri-Service Food Code. (T-3).

4.6.3.4.7. Infection Control/Bloodborne Pathogens. (T-3).

4.6.3.4.8. BLS/Obstructed airway conducted biennially. (T-3).

4.6.4. Coordination of Support to Formal Training Programs. Support for coordinated

undergraduate, professional practice, advanced degree dietitian programs, or independent

study programs for dietary managers must be coordinated through the AF SG Consultant

Dietitian/BSC Associate Chief for Dietetics. Additional staffing will not be authorized to

support these programs.

4.7. Workload Reporting.

4.7.1. Medical Expense Personnel Reporting System (MEPRS). MEPRS is an accounting

system used by the AF Medical Service that provides NM managers with manpower, cost

distribution, expense and workload reporting data. NM expense, personnel utilization and

workload data are collected for this system through manual and automated processes. Since

MEPRS data are used to determine manpower requirements, expense allocation and

productivity, NM input needs to be current, accurate and complete.

4.7.1.1. Personnel Time/Utilization. The timely and accurate control of personnel data is

essential for the total success of the MEPRS as personnel costs are the largest expense in

the MTF budget. Time (hours) worked is reported through manual entry into the Defense

Medical Human Resources System-internet (DMHRSi). Each individual is responsible

for accurately reporting hours worked to the correct Functional Cost Codes (FCC). (T-3).

A work center monitor should be appointed whose job it is to review DMHRSi for

16 AFMAN44-144 20 JANUARY 2016

accuracy, consistency, and appropriate FCCs, before they are submitted to the DMHRSi

Program Manager.

4.7.1.2. Contract Services/Sharing Agreements. For contracts in any area within dietetics

services, the cost should be allocated in the appropriate MEPRS account codes based on

the type of work accomplished. This allocation may be based on contractor estimates or

any method that NM management deems appropriate to reflect the percent of cost

allocated in each code based on the cost of labor and supplies used.

4.7.2. Functional Cost Codes (FCCs) and Usage. FCCs are used for all DoD Nutritional

Medicine organizations. FCCs are used to record NM expenditures, personnel time, and

workload. Specific written guidance governs MEPRS procedures and FCC usage: DoD

6010-13-M, Medical Expense and Performance Reporting System for Fixed Military Medical

and Dental Treatment Facilities Manual, and AFI 41-102, AF Medical Expense and

Performance Reporting System (MEPRS) for Fixed Military Medical and Dental Treatment

Facilities. The FCCs that are used most frequently in NM are as follows:

4.7.2.1. (EIA) Patient Food Operations. Provides meal service to inpatients, outpatients,

and transient patients. It includes activities such as routine inpatient rounds, therapeutic

menu development, patient tray assembly, and any activities related to patient feeding.

Supply expenditures include the following examples: enteral nutrition formulas, diet kits,

paper products for patient tray use only, insulated mugs and bowls used for the patient

tray line, selective menus, tray mats, office supplies used solely for inpatient feeding.

4.7.2.2. (EIB) Combined Food Operations. Includes subsistence, food preparation, and

services that are used for inpatient or non-patient feeding in the dining facility. This may

include menu and recipe development for regular menu items, sanitation of combined

areas, and subsistence accounting. Supply expenditures include the following examples:

cleaning supplies, plastic wrap, cooks’ knives, flatware, china, glassware, general office

supplies, and paper products used for both patient tray assembly and the dining facility.

4.7.2.3. (EIC) Inpatient Clinical Dietetics. Includes basic and comprehensive nutritional

care for patients. Activities include coordination of changes in diet requirements;

developing nutrition care plans; nutritional assessment and counseling, and clinical

nutrition management activities. Supply expenditures include pocket computers for

inpatient dietitians.

4.7.2.4. (FDC) Non-patient Food Operations. Includes nutrition management expenses

unrelated to patient care, but in support of staff and visitors. To include cashiers, serving

line, and dining facility functions. Supply expenses include dining facility trays, supplies

for cafeteria serving line, cash register tape, and napkins for dining facility use.

4.7.2.5. (BAL) Outpatient Nutrition Clinic. Includes comprehensive nutritional care to

outpatients including appointment scheduling, assessing and planning nutrition care,

individual and group instruction, and publication management of instruction materials

and handouts. Supply expenses include nutrient analysis programs used for weight

management, nutrition clinic office supplies, instructional materials used for outpatient

counseling.

4.7.2.6. (FCGH) Health Promotion. Includes awareness, education, and interventions

that support the Health Promotion target areas of Tobacco-Free Living, Nutritional

AFMAN44-144 20 JANUARY 2016 17

Fitness, Physical Activity, Healthy Weight and other Health Promotion initiatives as

indicated. EBBH should be used for administrative oversight of Health Promotion

programs. Non-MNT nutrition education should be counted as FCGH versus BALA.

4.7.3. Inpatient weighted nutrition procedures are provided to RMO monthly for inclusion in

MEPRS. This is critical manpower data and should be reviewed monthly by NM leadership

to ensure accuracy. (T-3).

18 AFMAN44-144 20 JANUARY 2016

Chapter 5

NUTRITION CARE

5.1. Medical Nutrition Therapy (MNT).

5.1.1. MNT is the development and provision of specific nutrition procedures in the

treatment of a disease or condition, or as a means to prevent or delay disease or

complications and optimize health and performance. MNT includes performing a

comprehensive nutrition assessment to determine a nutrition diagnosis, planning and

implementing a nutrition intervention using evidence-based nutrition practice guidelines, and

monitoring and evaluating an individual’s progress over subsequent visits. The level, content

and frequency of nutrition services that are appropriate for optimal care and nutrition

outcomes are individualized by the nutrition professional providing the MNT.

5.1.1.1. MNT is provided using the Nutrition Care Process (NCP) developed and

advocated for by AND. Documentation of care within the NCP utilizes established

terminology, with the goal of effectively communicating well defined components of

MNT. The NCP is a systematic approach to providing high quality nutrition care and

consists of four distinct and interrelated steps: nutrition assessment, diagnosis,

intervention, and monitoring/evaluation.

5.1.1.2. Evidence-Based Dietetics Practice and Standards. MNT is provided based on an

integration of the best available and up-to-date scientific evidence, professional expertise

and client values to improve outcomes. The AND’s NCM and PNCM are the preferred

source for evidence-based dietetics practice and patient education. However, other

professional sources may include but are not limited to: the AND’s Evidence Analysis

Library, Veteran’s Health Administration (VA)/DoD Clinical Practice Guidelines,

National Kidney Foundation, American Society for Parenteral and Enteral Nutrition

(ASPEN), American Heart Association, American Diabetes Association, the National

Institutes of Health (NIH), TRICARE Online, Medline Plus, Military One Source, and

the U.S. National Library of Medicine.

5.1.1.3. The NCM, PNCM, and SNCM are comprehensive online resources that cover all

aspects of nutrition management, and each MTF is encouraged to purchase each manual

that is appropriate to service their specific patient population, in the volume of

subscriptions adequate for their facility. Prior to purchasing, coordinate with AND and

the local Information Technology (IT)/Systems department to ensure the MTF’s range of

computer URLs can access the manual(s) at any one time up to the limit of subscriptions

purchased. Ideally, access to the NCM should be through the local intranet (vs. with a

username and password), but local IT guidance should be sought. Ensure the link to the

care manuals are centrally located, i.e., Medical Group (MDG) Intranet, for all MTF

personnel and providers to access, and market the availability and use of these resources.

5.1.2. Reproducible patient education materials from sources other than those listed above

may be utilized at the discretion of the credentialed RD.

5.1.3. Providing MNT.

AFMAN44-144 20 JANUARY 2016 19

5.1.3.1. Credentialed RDs and/or authorized diet therapy personnel (under the

supervision of a credentialed RD) provide MNT. (T-0). MNT is an essential component

of comprehensive healthcare. Appropriate screening processes should be developed to

identify those beneficiaries who would benefit from MNT in either the inpatient or

outpatient setting.

5.1.3.2. The screening and referral process should be coordinated to involve appropriate

medical, nursing and ancillary personnel, and to identify those patients who would most

benefit from the provision of MNT. .

5.1.3.3. Patients who will benefit from MNT include (but are not limited to) those with

diabetes, pediatric failure to thrive, dyslipidemia, hypertension, malnutrition, high-risk

pregnancy, renal disease, inflammatory bowel disease, celiac disease, liver disease,

obesity or pre or post bariatric surgery, metabolic syndrome, or are receiving enteral

and/or parenteral nutrition.

5.1.4. RDs and other providers such as physicians, dentists, certified nurse-midwives

(CNM), physician assistants (PA), nurse practitioners, and pharmacists may provide nutrition

education IAW their MTF clinical privileges and AFI 44-119, however this information

should be consistent with evidence based care guidelines and appropriate to the patient

condition or disease state.

5.1.4.1. Diet therapy craftsmen provide MNT as authorized by AF Form 628 and can be

authorized to provide MNT IAW Attachment 2, Diet Counseling Authorization Guide.

(T-3). Using this guide, the authorizing/credentialed RD determines what diets a diet

therapy craftsman may be certified on based on their assessment of the diet therapy

craftsman’s knowledge, ability, and skills. In addition, the authorizing/credentialed RD

defines the diet therapy craftsman’s scope of practice and required level of supervision

for each diet authorization.

5.1.4.2. MNT for inpatients may be provided without consult based on the patient’s

assessed nutrition risk per the MTF’s inpatient nutrition screening procedures. Medical

staff can also consult for inpatient NM services using SF 513, Medical Record –

Consultation Sheet, or electronic/MTF equivalent.

5.1.4.3. Inpatient diet orders, to include enteral nutrition support, nourishments, and

nutritional supplements, are ordered via the inpatient electronic medical record system.

(T-3).

5.1.4.4. Diet orders will be for regular or therapeutic diets offered at the facility. The

available therapeutic diets will be based upon the needs of the population served.

Components and defining characteristics of therapeutic diets will be consistent with

guidance from the Nutrition Care Manual. (T-0). Nonstandard diets requested by the

ordering provider to meet unique patient needs will be coordinated with the RD providing

care to that patient and/or the NM Flight Commander/Element Chief. See paragraph 5.3.

(T-3).

5.1.4.5. For Nutritional Medicine Clinics (NMCs) with an assigned RD, MNT for

outpatients is provided based on provider referral using SF 513 or electronic/MTF

equivalent. (T-3). Clients may also self-refer IAW MTF/Outpatient Nutrition Clinic

guidance. Generally, self-referrals to the outpatient nutrition clinic are limited to

20 AFMAN44-144 20 JANUARY 2016

participation in group classes. Local considerations, including characteristics of the

beneficiary population, resource constraints and MTF leadership priorities, will drive

decisions regarding provision of outpatient MNT. The MTF Commander will consider

options to ensure that all patients receive high quality nutrition services when the MTF

does not have an outpatient RD or diet therapist assigned, or when the need for MNT

within the beneficiary population exceeds resources available. (T-3). Possible options

include hiring a full-time or part-time civilian RD, contracting for nutrition services, tele-

wellness referral (if available/appropriate), or referral to an off-base provider if the MNT

benefit is covered by TRICARE. The MAJCOM Dietitian is also a resource for

coordinating MNT.

5.1.5. MNT Outcomes and Outcomes Management

5.1.5.1. MNT outcomes are measurable benefits and include: improvements in patients’

clinical, functional/behavioral, quality of life/satisfaction, or financial status as a direct

result of MNT. Tracking and documenting MNT outcomes is important because in

managed care, medical services are reimbursable insurance benefits only if they produce

positive outcomes in a cost-effective manner.

5.1.5.2. For NMCs with an assigned RD, each MTF will identify, prioritize and track

MNT outcomes significant for their patient population and relevant to the AF and/or the

MTF’s interdisciplinary teams, case managers, and disease and condition management

programs. (T-3). Committees such as the Integrated Delivery System (IDS), Population

Health Working Group, and Environment of Care, may be resourceful avenues for

tracking and marketing MNT outcomes.

5.1.5.3. The USAF Dietetics Benchmarking Tool can be used to track key metrics within

USAF dietetics. Within the domain of MNT and clinical dietetics, relevant metrics for

inpatients include: number of inpatient meals, number of inpatients, weighted diet

census, inpatient weighted nutrition procedures, and staffing metrics. For outpatient

MNT, RVU generation, Defense Enrollment Eligibility Reporting System (DEERS)

population numbers, presence of civilian and contracted RDs providing outpatient MNT,

and relevant MEPRS data should be tracked. This information is reported up from each

NM to the MAJCOM Dietitian and to the AF SG Consultant Dietitian. (T-3). Metrics

being tracked by the Population Health Working Group, such as patients with abnormal

HgbA

C values or elevated lipid levels, may be appropriate targets for MNT outcomes

collection. For RDs or Diet Therapy Craftsman who must divide their time between

population health and MNT, this information may assist in prioritizing patient

populations to serve and time spent. The NM Flight Commander/Element Chief should

be aware of unique factors within the population (e.g., related to the mission of the

installation), top 5 or top 10 ICD-9 diagnosis codes pertinent to nutrition, stated concerns

or objectives of the MTF leadership or installation leadership that are pertinent to

dietetics, and should use this information when establishing local outcomes for tracking.

The NM Flight Commander/Element Chief should also consult with MTF coding experts,

Resource Management Office (RMO) personnel, and other MTF personnel, to understand

expectations regarding RVU generation, tracking and facility standards which will

pertain to the NM Flight/Element. NM Flight Commander/Element Chief should look to

optimize coding and documentation in accordance with local and USAF guidance. When

selecting appropriate local outcomes for tracking MNT effectiveness, the NM Flight

AFMAN44-144 20 JANUARY 2016 21

Commander/Element Chief should consider use of the Nutrition Care Process (NCP).

The NCP is appropriate for use at the individual patient level, or for populations and

groups. Appropriate population assessment, establishing specific nutrition problems

which require nutrition intervention, and selection of meaningful monitoring and

evaluation criteria are part of effective outcomes management.

5.2. Patient Rights and Privacy.

5.2.1. All patients have the right to be informed about and participate in their nutrition care.

Reasonable efforts should be made to ensure patients’ food preferences are noted, menus

individualized, learning needs accommodated and special needs are met when applicable.

NM personnel will comply with all Privacy Act guidance and instructions such as AFI 33-

332, Air Force Privacy Act Program, and the Health Insurance Portability and

Accountability Act (HIPAA). (T-0).

5.3. Nutrition Screening.

5.3.1. MTF/NM will develop a nutrition screening process to determine the nutritional risk

for both inpatients and outpatients. (T-0). The screening and referral process should include

appropriate medical, nursing and ancillary personnel both in development and

implementation to best capture those patients who would most benefit from the provision of

MNT.

5.3.2. MTF policies and operating instructions will detail both inpatient and outpatient

populations to be screened, screening criteria and local processes and documentation

techniques. (T-3). A RD will educate the MTF staff on nutrition screening policies and

procedures as applicable. (T-3). Regardless of the screening process developed, the NM

Flight Commander/Element Chief should ensure that existing policies (inpatient and

outpatient) are updated appropriately, compliance with the policy is enforced, training is

conducted regularly, and modifications to the process are reflected in policy revisions.

5.3.2.1. Nutrition screening is not considered part of the Nutrition Care Process, but is an

essential precursor to the NCP. A selected nutrition screening process should reflect the

unique needs of the population served as well as the resources and considerations of the

facility. The AND’s Evidence Analysis Library (EAL) can serve as a resource to locate

validated, reliable screening and assessment tools. Other resources for use in developing

a nutrition screening process include, but are not limited to, the AND’s Pocket Guide to

Nutrition Assessment, ASPEN Core Curriculum or practice guidelines, and the CNM

Nutrition Screening Practices in Health Care Organizations.

5.3.3. Inpatient screening.

5.3.3.1. It is advisable that the existing admission assessment documentation (e.g., initial

nursing assessment and/or the history and physical) be reviewed and incorporated into a

nutrition screening process. This documentation may be a standard Essentris form and

modifications should be coordinated with Information Technology (IT) staff.

5.3.3.2. Inpatient nutrition screening is completed within 24 hours of admission to the

MTF. (T-0). This screening can be conducted by medical personnel outside of NM

according to locally developed processes. NM Flight Commander/Element Chief should

22 AFMAN44-144 20 JANUARY 2016

regularly monitor the performance of the local screening process to ensure compliance

and efficacy.

5.3.3.3. Pre-admission screening procedures are developed depending upon NM

resources and facility needs.

5.3.3.4. Dietitians will initiate the provision of MNT for inpatients identified as being at

nutrition risk, based upon local procedures and timelines. (T-3).

5.3.4. Outpatient screening

5.3.4.1. Diagnoses of interest should include: diabetes, pediatric failure to thrive,

dyslipidemia, hypertension, malnutrition, high-risk pregnancy, renal disease,

inflammatory bowel disease, celiac disease, liver disease, obesity or pre or post bariatric

surgery, metabolic syndrome, or those requiring enteral and/or parenteral nutrition. Other

diagnoses could be added based upon local population needs as determined by providers.

5.3.4.2. Coordination with the local contracted entity performing appointment scheduling

is recommended. Additionally, the provider staff should be educated on appropriate

wording and information to include in consults to NM. This will minimize inappropriate

self-referrals or unclear provider referrals.

5.3.4.3. NM/MTF will develop operating guidance for an outpatient nutrition clinic to

include patient referral, scheduling, class preparation, patient/family check-in procedures,

lesson plans, education evaluation tools, communication with other health care

professionals, and documentation. (T-3). Upon outpatient check in, two patient

identifiers need to be requested to validate the patient’s identify. (T-0).

5.3.5. Additional considerations for specific inpatient populations such as obstetrics or

pediatrics are considered as appropriate.

5.4. Documentation and Peer Review.

5.4.1. MNT is documented in the inpatient EHR (Essentris) and outpatient electronic health

record (AHLTA) or other MTF equivalent using the Assessment, Diagnosis, Intervention,

Monitoring, Evaluation (A.D.I.M.E.) format, as applicable. (T-3).

5.4.1.1. Additional hard-copy document forms include SF 513, SF 509, Medical Record

Progress Note, and SF 600, Chronological Record of Medical Care.

5.4.1.2. All medical record entries must include date and time, signature block, and

nutrition care provider signature, or as applicable with the local EHR. (T-3).

5.4.1.2.1. When documenting MNT via hard-copy forms the signature block format

will be (T-3):

Name, Grade, USAF, BSC

AFSC 43D3, Registered Dietitian

Name, Grade, USAF

AFSC 4D0X1, Diet Therapy Journeyman/Craftsman

5.4.2. Assessment data is found on the following forms or electronic/MTF equivalent: AF

Form 2572, Nutritional Assessment of Dietary Intake; AF Form 2508, Calorie Count; DD

AFMAN44-144 20 JANUARY 2016 23

Form 792, Twenty-four Hour Patient Intake and Output Worksheet; and AF Form 3067,

Intravenous Record.

5.4.3. Peer review is conducted quarterly. See paragraphs 9.2.4.4 and 9.2.4.4.1-3 for peer

review details. (T-3).

5.4.4. RDs conduct and attend inpatient dietary patient rounds, medical patient rounds,

nutrition support committee rounds, and discharge planning whenever possible. (T-3).

Pertinent patient data/notes are recorded in the MTF electronic health record. (T-3).

5.4.5. Participation in such interdisciplinary, patient-centered activities enhances

communication between care providers and allows the RD to obtain additional patient

information for assessments and re-assessments, menu selection assistance, information

regarding food preferences or intolerances, food allergies, educational needs, etc. In

addition, nutrition needs after discharge can be coordinated as needed.

5.5. Ordering Inpatient Meals and Nourishments.

5.5.1. Nursing Service uses AF Form 1094, Diet Order, AF Form 2567, Diet Order Change,

Composite Health Care System (CHCS), Essentris or electronic/MTF equivalent to order or

communicate the following to NM: therapeutic and non-therapeutic diets, Nothing Per Oral

(NPO), or out on pass; tube feedings; Total Parenteral Nutrition (TPN); food allergies; age of

pediatric patients; special tray preparations; and new patient admissions, discharges, or

transfers.

5.5.1.1. Local NM/MTF establishes guidance when diet orders and diet order changes

are required by NM to properly and effectively serve patient meals and nourishments.

Ideally, Nursing Service submits diet orders daily NLT 0500 hours, and diet order

changes NLT 1000 and 1500 hours.

5.5.1.2. All diet orders will comply with the AND as well as both print and online

versions of the NCM, PNCM, and SNCM. (T-0).

5.5.1.3. Therapeutic in-flight meals (TIM) for patients in the aeromedical evacuation

system are ordered using AF Form 2464, CTIM Telephone Diet Order, or electronic/MTF

equivalent. (T-3).

5.5.2. Nourishment Service.

5.5.2.1. Individual Nourishments.

5.5.2.1.1. The RD or other authorized health care provider will order additional

individual patient nourishments on AF Form 2568, Nourishment Request, on AF

Form 1094 or electronic/MTF-equivalent as appropriate. (T-3).

5.5.2.1.2. NM personnel ensure the individual nourishment is in compliance with the

current diet order. (T-3). NM will call the RD, Nursing Service, and/or patient’s

provider to clarify all ambiguous nourishment requests. (T-3).

5.5.2.1.3. All individual nourishments, diet specific or additionally ordered, will be

maintained on AF Form 1741 or electronic/MTF-equivalent. (T-3).

24 AFMAN44-144 20 JANUARY 2016

5.5.2.1.4. NM prepares nourishments and nourishment labels to include: patient’s

name, inpatient unit, room number, hour to serve, food item(s), preparation date and

time, and expiration date. (T-3).

5.5.2.1.5. NM delivers nourishments to Nursing Service or patients based on local

guidance. (T-3).

5.5.2.2. Bulk Nourishments.

5.5.2.2.1. NM will develop guidance for Nursing Service to order bulk nourishments

for supplemental patient feeding. (T-3). For example, frozen meals are commonly

obtained by nutritional medicine and distributed to the inpatient units on a nightly

basis in case a patient is admitted after the evening meal tray collection, ensuring

these patients receive a hot meal as needed. In addition, meals for residents working

overnight are commonly prepared and delivered IAW facility-specific guidance.

5.5.2.2.1.1. Outpatient clinics will procure their own supply of patient

nourishments using their own Government Purchase Card (GPC) and funding

source. (T-3). NM does not furnish outpatients or outpatient clinics with

nourishments. (T-3).

5.5.2.2.1.2. Nursing Service will order bulk nourishments on AF Form 2568 or

electronic/MTF-equivalent. NM will approve, prepare, and deliver bulk

nourishment requests IAW local guidance. (T-3). Nursing will sign for receipt of

nourishment delivery. (T-3).

5.5.2.2.1.3. All bulk nourishment items are labeled with the following: Inpatient

unit, food item, date and time prepared, and expiration date. (T-3).

5.5.2.3. All nourishments, individual or bulk, are for patient feeding only. Nourishments

are not to be consumed by hospital staff or visitors. (T-3).

5.5.2.4. Nourishments are modified based on food tolerances, food allergies, preferences

and diet order as appropriate and whenever possible. (T-3).

5.5.2.5. Inpatient Nourishment Refrigerators.

5.5.2.5.1. Nursing Service will monitor temperatures for inpatient refrigerators and

freezers used for patient nourishments. (T-3).

5.5.2.5.2. Temperatures are monitored three times a day with thermometers located

in the interior of the refrigerator and freezer compartments. (T-3). The outside

temperature gauge on the equipment is not always reliable and will not be used to

monitor interior temperatures. (T-3).

5.5.2.5.3. Record temperatures on a temperature chart according to local guidance.

(T-3).

5.5.2.5.4. Acceptable temperature range for refrigerators is 34 to 40˚ Fahrenheit. The

acceptable temperature range for freezers is -10 to 10˚ Fahrenheit. Acceptable

temperature ranges should adhere to AFMAN 48-147_IP, Tri-Service Food Code.

5.5.2.5.5. Local guidance must indicate specific procedures to be followed should

temperatures fall below standards. (T-3).

AFMAN44-144 20 JANUARY 2016 25

5.6. Inpatient Meal Service

5.6.1. NM will develop local procedures for providing inpatient meal service. (T-3). Several

variations of service are available and may include selective menus, nonselective menus,

room service or hotel style, or a combination of them all.

5.6.1.1. Procedures will outline how often patients on non-selective therapeutic diets are

visited on inpatient dietary rounds as applicable. (T-3).

5.6.2. Menu tickets, hard copy or electronic (Computrition), are used to assemble and

identify food trays for inpatients. (T-3). In accordance with Joint Commission standards,

menu tickets are to contain two patient identifiers. (T-0). As such, menu tickets are treated

as personal information and are protected under the Health Insurance Portability and

Accountability Act (HIPAA) and must be either filed or disposed of in an appropriate and

consistent manner (i.e. shredded upon discharge). (T-3). In addition, menu tickets must

contain the appropriate privacy act information, such as: “FOR OFFICIAL USE ONLY.

This page contains information protected under the Privacy Act of 1974, as amended. Do not

disclose without authorization”. (T-0).

5.6.2.1. The NM flight of each MTF generates their own menu tickets based on type of

menus offered, type food service operation employed, and existing specific therapeutic

diets. (T-3). This allows for personalization of menu items relative the diet-types offered

and enables menus to be updated as needed based on food item availability from their

prime vendor.

5.6.3. Menu patterns are modified based on food tolerances, food allergies, preferences and

diet order as appropriate and whenever possible. (T-3).

5.6.4. Salt Substitute. Do not give salt substitute to patients unless ordered by the healthcare

provider. Use mixtures of appropriate herbs and spices (non-sodium and non-potassium

based) instead. (T-3).

5.6.5. Disposable Tray Service. Isolation trays need not be routinely used for patients with

contagious diseases or infections per AFI 44-108, Infection Control Program. (T-3). Use

disposable tray service for radiation ablation therapy patients according to local procedures.

(T-3).

5.6.6. Psychiatric Patients. Nursing Service orders “paper products for precautionary

measures” for patients who could hurt themselves or others. Identify these patients by

stamping menu slips with “paper products.” (T-3). Other patient populations (e.g., radiation

ablation) may also require similar considerations; policies should reflect patient needs.

5.6.7. Mothers of breastfed pediatric inpatients are authorized inpatient meal service.

Follow all procedures outlined above for inpatients. (T-3).

5.6.7.1. Provisions may be made to provide postpartum mothers and their guest a one-

time “Proud Parent” meal. One guest of the post-partum mother may purchase a meal at

the proportional BDFA rate and must pay for the meal prior to the meal service.

5.7. Dietary Kardex (AF Form 1741) or Electronic/MTF-Equivalent.

5.7.1. NM will establish local procedures for use of AF Form 1741 or electronic/MTF-

equivalent. (T-3).

26 AFMAN44-144 20 JANUARY 2016

5.7.2. Create and complete a patient Kardex to communicate current and future nutritional

care to other dietitians and diet therapy personnel. (T-3).

5.7.2.1. Patient information to record, maintain, and update on the Kardex include

patient’s name, age, gender, diet order, nutritional risk level, food preferences, food

allergies, scheduled nourishments, nutrient/drug interactions, etc. As appropriate, these

considerations will be incorporated into provision of patient meals (see 5.5). (T-3).

5.7.3. Initial/sign each entry made to the patient Kardex when more than one person

performs dietary rounds or charting procedures. (T-3).

5.7.4. A patient Kardex is maintained until the patient is discharged. (T-3). Create

procedures to maintain a Kardex file for patients who are frequently re-admitted to ensure

continuity of care. (T-3).

5.7.5. Use the reverse side of AF Form 1741 to compute nonstandard therapeutic diets. (T-

3).

5.7.5.1. Modify the therapeutic menu pattern to reflect dietary restrictions and patient

preferences for use when writing the therapeutic menu patterns, as applicable. (T-3).

5.8. Meal Hours

5.8.1. The MTF Commander approves meal hours for inpatients and the NM dining facility.

(T-3).

5.8.2. For inpatients, the number of hours between the evening meal time and breakfast the

following morning must not exceed 15 hours. (T-3).

5.8.3. Adjust meal hours slightly to provide adequate preflight support of patients being

moved in the aeromedical evacuation system. (T-3). Feed post-flight aeromedical evacuation

patients at normal meal hours or as needed, depending on when the patients last ate a meal.

(T-3). If frozen meals are available, they may be given to such patients or medical center

residents that missed regular meal times due to duty or travel.

5.9. Bedside Tray Service.

5.9.1. NM prepares and delivers patient meal trays per diet order and patient preferences and

delivers to Nursing Service or patient’s bedside based on local guidance. (T-3).

5.9.2. Nursing Service prepares patients for eating, checks trays against diet orders before

serving according to local policy, and helps patients with feeding as needed. (T-3). Preparing

patients for the meal includes raising the bed, clearing bedside tables, etc. Note: This

instruction does not relieve the NM Officer or diet therapy supervisor of the responsibility for

checking patient tray service.

5.9.3. Nursing Service removes soiled trays from bedsides and returns trays to the food cart,

and checks trays for possible contamination prior to returning them to NM. (T-3).

5.9.3.1. Dishware and trays visibly contaminated with vomit, blood, drainage, secretions,

etc., will be wiped clean with hospital-approved cleaning solution before returning them

to the food service cart. (T-3). All contaminated medical supplies will be removed from

meal trays and disposed of on the inpatient unit. (T-3).

AFMAN44-144 20 JANUARY 2016 27

5.9.4. Nursing Service will check the food cart to ensure no contaminated paper service trays

are returned to the kitchen. (T-3). If a contaminated tray and/or its components are returned

to NM staging area, NM personnel will contact the responsible inpatient unit, and nursing

service personnel will be asked to retrieve and properly dispose of the contaminated material

on the tray. (T-3).

5.9.5. For patients receiving radiation ablation therapy, dispose of all disposable dishware on

the inpatient unit. (T-3). Do not return to NM any items taken into the patient’s room. (T-3).

5.9.6. For patients on precautions to prevent injury to self or others, all disposable dishware

is returned to NM on the food cart and disposed of in the usual manner. (T-3).

5.10. Enteral Nutrition, Medical Foods, and Infant Formulas.

5.10.1. Enteral formulas and other medical foods, and infant formulas are supply items

purchased by NM via the Government Purchase Card (GPC) for inpatient use. (T-3).

5.10.2. Providers will order appropriate enteral nutrition on AF Form 3066 or

electronic/MTF-equivalent, indicating product name, strength, and rate. (T-3). If feeding rate

is less than 24 hours, indicate the times of feedings and total number of milliliters per day.

5.10.2.1. Clinical dietitians will advise providers regarding the nutrient composition and

administration rates of enteral formulas available and will provide MNT to patients

receiving enteral nutrition following available evidence-based practice guidelines and

clinical judgment. (T-3).

5.10.3. Nursing Service personnel will order enteral nutrition on AF Form 1094, AF Form

2567, or electronic/MTF-equivalent, and include patient’s name, Uniform Cost Accounting

(UCA) code, unit, room number, enteral formula name, strength, and rate required. (T-3).

5.10.4. Nursing service will administer all enteral nutrition IAW the physician’s orders. (T-

3).

5.10.5. Enteral formula feeding bags and administration sets are procured by the inpatient

unit/ASF from Medical Materiel, as applicable. (T-3).

5.10.6. Feeding sets should be changed out according to local policy and manufacturer

guidelines.

5.10.7. NM will maintain an adequate supply of enteral formula products and deliver enteral

formulas to the inpatient unit. (T-3). Enteral formulas are routinely provided for a 24-hour

period. Enteral formula should be administered in such a way as to minimize waste (e.g. do

not hang 24 hours’ worth of formula when the maximum hang time for that system is 8

hours).

5.10.7.1. In MTFs without an assigned inpatient dietitian, enteral formulas and medical

foods may be purchased, prepared and dispensed by the Pharmacy or Nursing Service.

5.10.7.2. Infant formulas are supply items and are not procured, stored, or supplied by

NM. (T-3).

5.10.8. Enteral formulas and medical foods are not routinely issued to outpatients in CONUS

medical facilities. Arrangements for home enteral nutrition may be available through

28 AFMAN44-144 20 JANUARY 2016

discharge planning; however, the MTF Commander has the authority to approve Pharmacy to

dispense these items on a patient-by-patient basis. (T-3).

5.10.8.1. Medical foods for outpatients with inborn errors of metabolism may be

requested and dispensed by the Pharmacy on the written prescription of a provider IAW

AFI 44-102, Medical Care Management.

5.10.9. The MTF’s enteral formulary must be approved by a multi-disciplinary committee,

such as the Pharmacy and Therapeutics (P&T) Committee. (T-3). It is recommended that

there be a RD on the P&T Committee.

5.11. Parenteral Nutrition (TPN, PPN).

5.11.1. Providers will order TPN or PPN on AF Form 3066 or electronic/MTF-equivalent.

(T-3).

5.11.1.1. Clinical dietitians will advise providers regarding the nutrient composition and

administration rates of parenteral nutrition and will provide MNT to patients receiving

parenteral nutrition following available evidence based practice guidelines and clinical

judgment. (T-3).

5.11.2. Nursing Service personnel will order parenteral nutrition on AF Form 1094, AF

Form 2567, or electronic/MTF-equivalent. (T-3).

5.11.3. Inpatient pharmacy is responsible for preparing and delivering parenteral formulas to

the inpatient unit. (T-3). NM does not prepare, provide, or administer parenteral nutrition

solutions. (T-3).

5.11.4. Arrangements for home TPN are available through discharge planning.

5.12. Therapeutic Diets for Outpatients.

5.12.1. Outpatients are generally not provided meals at the expense of the NMF. There are

situations that vary between installations wherein meals or snacks are provided to diabetic

patients who have been in the Emergency Department (ED) for over 4 hours and admission

to the hospital is anticipated.

5.12.2. Various outpatient locations (i.e. ED, Hematology/Oncology) may request snack

items for patients for whom they anticipate an extended stay in the MTF while in nursing

care that require nutrition, and may be requested on SF 513 or electronic/MTF equivalent.

5.13. Patient and Family Education.

5.13.1. Patient and family education is provided throughout the continuum of care to meet

ongoing nutritional and behavioral needs. (T-3). It should include interactive, collaborative,

and interdisciplinary processes that promote healthy behavior and encourage patient/family

involvement in the nutritional plan of care.

5.13.2. The need for patient and family education for inpatients is assessed during

implementation of the NCP. (T-3). The need for outpatient education is assessed at clinic

encounters. (T-3).

5.13.3. Nutrition intervention takes into consideration cultural and religious practices,

emotional barriers, desire and motivation to learn, physical and cognitive limitations,

language barriers, and financial implication of care choices.

AFMAN44-144 20 JANUARY 2016 29

5.13.4. Patient and family education is interactive and addresses potential nutrient-drug

interactions, nutrition interventions, modified diets, patient and family responsibilities, and

follow-up information on accessing future care or community resources. (T-3).

5.13.5. Patient education is documented as part of the care provided, in the inpatient or

outpatient EHR as appropriate. (T-3). Additional hard-copy document forms include SF

513, SF 509, and SF 600. Nutrition education and MNT for patients/families commonly

offered should be IAW AFI 44-102 and/or based on the needs of the MTF/base patient

population and NM staffing and resources.

5.14. Health Promotion Nutrition.

5.14.1. Nutrition plays an important role in the AF Health Promotion Program (HPP).

Health status is dependent upon the collective behaviors, attitudes, knowledge, and beliefs of

family and community. To meet nutrition and fitness goals and outcomes, all interventions

should use multiple modalities of the Intervention Pyramid (see AFI 40-101, Guidance

Document). Delivery of programs and services are provided in locations where target

populations live, work, and play with emphasis on high population reach programs and

strategies.

5.14.2. The scope of practice for Health Promotion is to assess base population and

environmental nutrition needs, plan, collaborate, implement and evaluate community

nutrition strategies, interventions and programs and use multiple, evidence-based strategies

and interventions with the largest reach to impact population eating behaviors and outcomes.

Health Promotion Nutrition is addressed in AFI 40-104.

30 AFMAN44-144 20 JANUARY 2016

Chapter 6

FOOD PRODUCTION AND SERVICE

6.1. Production Planning.

6.1.1. (Automated) Production Planning. NM personnel will utilize Computrition to

automate their production planning processes IAW the current instructions outlined in the

Computrition Training & Reference Guide and Food Operations Management (FOM) User’s

Reference Guide. (T-3).

6.1.1.1. Menu Maintenance.

6.1.1.1.1. All meal changes and assignment of meals to cycle days is performed

under the Menu Maintenance function in Computrition. (T-3).

6.1.1.1.2. All recipes and food items are verified as being on the menu either by

crosschecking the screen or by using the View at Glance Report. (T-3).

6.1.1.1.3. Once the recipes and food items are verified, run the Menu Item Cost

Report. (T-3). This report must be run at least monthly, however, running the report

weekly to update the food costs in the system is recommended. (T-3).

6.1.1.1.4. Next, run the Recipe Price Report to obtain the updated costs. (T-3). Note:

The Menu Cost Report must be run prior to running the Recipe Price Report. (T-3).

6.1.1.2. Forecasting.

6.1.1.2.1. Forecasting is available when the menu is corrected and verified.

6.1.1.2.2. Forecast for menu items that require controlled quantity production. (T-3).

Daily consumables such as PC condiments, fountain soda, fresh fruit and other

similar items do not need to be forecasted within Computrition, but can be monitored

each month in Computrition to better help with ordering. To monitor daily

consumables, create a Cost Center in the Cost Center Table (system

setup>tables>items>cost centers) and use the Requisition Out to show how much was

used during the week. The review of the previous month’s daily consumables

utilization should assist with ordering/forecasting.

6.1.1.2.3. The Menu Maintenance function of Computrition is where the site

manager identifies what courses are to be forecasted (soup, entree, vegetable, etc.).

6.1.1.2.4. In Computrition, go to Menus Post Meal Count function and enter the

number of meals served into the actual count fields. (T-3). Click calculated prepared

button to automatically populate amounts in the prepared field. (T-3). There are three

options for forecasting to choose from: 1. Do not apply batching, Forecast equals

Prepared (selected by default). This option sets all prepared amounts to forecasts

amounts. 2. Batch (each menu meal separately). Select this option if batching should

be included for prepared amounts. 3. Overwrite existing prepared figures. Select this

option to overwrite any numbers that have been entered in the prepared fields. Once

an option is chosen, click in the Served field of each recipe and type the amounts

served. When amounts are placed in this field, figures are automatically entered into

AFMAN44-144 20 JANUARY 2016 31

the Leftover and Next Time fields. The Percent Count field is active if the Served

amount is less than the prepared amount. Click the Review Counts button to show

counts and have the ability to copy them forward to the next time the menu is served.

A number must be in the Served and Next Time fields of each recipe in order for

counts to be copy forward.

6.1.1.3. Calculate Yield Adjust. The post meal count function of Computrition to

forecast must be used at least five days prior to the day that the user would like to yield

adjust. (T-3). This is necessary for the pulling of food items three days prior to use (early

withdrawal; frozen meats, etc.) and prepping of items two days prior to actual meal

service (pre-preparation; gelatins, etc.).

6.1.1.4. Run Production Reports. Once the Post Meal Counts have been completed and

copied forward, run the Production Worksheet Report. (T-3). This report provides a list

of recipes and amounts required for producing the selected menus and meals for the

selected dates. Also, print the Menu Scaled Recipes Report this will print recipes for the

date and meal selected scaled to the amount required in the menus. (T-3).

6.1.2. (Manual) Production Planning. The Production Worksheet Report (Computrition) is

normally used to perform production planning. If Computrition or computer systems are

down, temporarily perform manual production planning (forecast food production needs for

the meals in the cycle menu, establish a food use monitoring system, and communicate

instructions to food production personnel in the planning, preparing, cooking and serving of

meals) according to local procedures. (T-3). Facilities with inpatient feeding only should

establish an alternate method of creating an audit trail for food use, AF Form 543, Food Issue

Record, menus and tally sheets. If the NM cash register does not have the capability of

inputting patient meal counts, menu items served to patients and the total number of servings

provided to patients must be documented according to local procedures. (T-3). The tally

sheet for patient meals and late trays, to include therapeutic menus, should also be tracked

and recorded according to local procedures.

6.2. Purchasing Non-Food Supplies.

6.2.1. Items for Patient Tray Service. Establish local operating procedures to request and

purchase nonfood supplies needed for patient tray service, dining facility operations, food

production, and sanitation. (T-3). These procedures must reflect types of items needed,

amounts used, replacement factors, stock levels, and delivery times. (T-3). Prepackaged

flatware sets and dining packets containing straw, napkin and condiments (sugar, salt, pepper

and sugar substitute) are allowed and are ordered by NM as supply items. (T-3).

6.2.2. Enteral Formulas and other Medical Foods, and Infant Formulas. See Chapter 5,

Section 5.10 for information on purchasing these items.

6.3. Food Portion and Waste Control.

6.3.1. Standardized recipes, serving utensils, and dishes are used to control portions, quality,

and cost of food served. (T-3). Foods should be cooked progressively, in small amounts as

needed to help ensure a fresher, more acceptable product. This practice also results in less

waste by cooking only what is needed as it is needed. NM production managers should

periodically observe plate waste in the dish room from dining facility service and patient

32 AFMAN44-144 20 JANUARY 2016

trays to evaluate patient’s consumption related to food quality, taste, portion control, quantity

prepared and acceptability.

6.4. Hazard Analysis and Critical Control Point (HACCP) HACCP is the prevention-based

food service safety system that must be used in NM. HACCP systems are designed to prevent

the occurrence of potential food safety problems. HACCP involves seven principles.

6.4.1. Analyze hazards. Potential food-related hazards and measures to control potential

hazards are identified. (T-0). The hazard could be biological, such as a microbe; chemical,

such as a toxin; or physical, such as ground glass or metal fragments.

6.4.2. Identify critical control points. (T-0). These are points in a food's production, from its

raw state through processing and shipping to consumption by the consumer, at which the

potential hazard can be controlled or eliminated. Examples are cooking, cooling, and

packaging.

6.4.3. Establish preventive measures with critical limits for each control point. (T-0). For

example, for a cooked food this might include setting the minimum cooking temperature and

time required to ensure the elimination of any harmful microbes.

6.4.4. Establish procedures to monitor the critical control points. (T-0). Such procedures

might include determining how and by whom cooking time and temperature should be

monitored.

6.4.5. Establish corrective actions to take when monitoring shows that a critical limit has not

been met. (T-0). For example, reprocessing or disposing of food if the minimum cooking

temperature is not met.

6.4.6. Establish procedures to verify that the system is working properly--for example,

testing time-and-temperature recording devices to verify that a cooking unit is working

properly. (T-0).

6.4.7. Establish effective record keeping documenting the HACCP system. (T-0). This

would include records of hazards and their control methods, the monitoring of safety

requirements and action taken to correct potential problems.

6.4.8. Food Temperatures. NM personnel complete AF Form 2582, Food Temperature

Chart, or local equivalent, before and during each meal to ensure foods are served at

appropriate temperatures IAW the AFMAN 48-147_IP, Tri-Service Food Code. (T-0).

Foods at other than optimal temperatures must be reheated or chilled as appropriate. (T-0).

6.4.9. Storing Subsistence Items. Subsistence storage rooms and refrigerators/freezers

MUST remain locked at all times when not in use. (T-0). Entry for all but authorized

personnel must be prohibited. (T-0). NM refrigerators should have the following: an

accurate thermometer inside the unit which can be viewed from outside the

refrigerator/freezer, a temperature chart to record readings taken at specific times IAW local

guidance unless centrally monitored by Facilities Management, a warning sign such as

“Determine No One is Inside Before Locking,” a safety lock release that lets the door open

from inside when externally locked, an electric light preferably mounted overhead with a

glass-dome bulb protector and a grid-type metal cover, and a sign indicating the type of

food(s) stored within and the required temperature range IAW the AFMAN 48-147_IP, Tri-

Service Food Code.

AFMAN44-144 20 JANUARY 2016 33

6.5. Sanitation and Infection Control. Sanitation and Infection Control. Refer to AFI 48-116,

Food Safety Program, AFMAN 48-147_IP, Tri-Service Food Code, AFI 48-117, Public Facility

Sanitation, and AFI 44-108, Infection Prevention and Control Program, for NM sanitation and

infection control policies. Limit access to food preparation and service areas by unauthorized

personnel. NM personnel performing dishwashing duties must always wear gloves as a

protective device against possible infections or contamination. (T-3).

6.6. Patient Tray Assembly. Patient trays are assembled using a centralized food service,

which places all food service workers under the supervision of the NM officer or diet therapy

supervisor. (T-3). Using the right patient tray service system aids in the appropriate use of

employees assigned. The size of the medical treatment facility determines the type of patient

tray assembly system used.

6.6.1. Heated Base With Enclosed Pellet System. Larger MTFs use the heated base with

enclosed pellet system. (T-3). This system can also be used to augment the hot and cold cart

system used in smaller facilities, if the tray carts cannot maintain a high enough temperature

for hot foods.

6.6.2. Hot and Cold Tray Cart System. The hot and cold tray cart systems are typically used

at smaller facilities due to reduced labor requirements. One person can prepare all trays and

additional personnel are needed only to deliver trays to patient inpatient units. If an MTF's

number of operational beds would normally dictate using a hot/cold food cart system, but the

contingency plan calls for an expansion capacity making the heated base with pellet system

desirable, retain and use the heated base with enclosed pellets system and conveyor belt.

6.6.3. Insulated Stacking Trays System. The Insulated Stacking Tray System is generally

used at small facilities that are supported by base food service.

6.6.4. Point of Service Trolley/Cart System. This system is intended for cook-serve meals to

be plated on the patient care units by food service workers. Food service workers will obtain

meal orders from patients at the bedside and then plate the food from a trolley/cart outside

the room. The trolley/cart typically has heated wells and refrigeration compartments to keep

foods at proper temperature. This system is designed to cater to patient food preferences at

mealtimes.

34 AFMAN44-144 20 JANUARY 2016

Chapter 7

FINANCIAL MANAGEMENT

7.1. Budgets. The purpose of an operations and maintenance budget is to plan for the

expenditure of funds in a manner that meets mission objectives within financial limitations. The

budget planning process requires time and effort to ensure sufficient funds are available for NM

operations. The MTF budget cycle usually begins a few months before the start of the fiscal

year. NM operating budgets are developed to include projections for supplies, equipment

purchases and maintenance costs, and required travel. To develop an operating budget the

following steps are followed:

7.1.1. Collect data, to include the previous year’s budget, actual expenses for the last year,

projections for new programs or services, inflation rate, and workload trends. (T-3).

7.1.2. Compare data: Analyze last year’s budget versus expenditures, and reasons for

variation. (T-3).

7.1.3. Compile data: Obtain current cost data for equipment and supplies, projected supply

usage, anticipating needs in all NM areas, including educational materials. (T-3). Obtain

input from key NM personnel. (T-3).

7.1.4. Draft the budget: Determine annual and quarterly costs. (T-3).

7.2. Prime Vendor. Prime Vendor is a concept of support whereby a single commercial

distributor serves as the major provider of products to various federal customers within a

geographical region or zone. The vendor supplies commercially available subsistence items

under a contractual agreement established by the Defense Supply Center Philadelphia (DSCP) or

Department of Veterans Affairs (DVA).

7.2.1. NM personnel must have a thorough knowledge of their Prime Vendor contract,

especially renewal timeframes. (T-3). Prime Vendor contracts are developed by DSCP in a

number of steps called the acquisition process. NM communication throughout this process

for generating new or renewing existing contracts is essential ensure specific NM subsistence

purchasing needs are met. Further information on establishing Prime Vendor contracts can

be found in the DSCP Prime Vendor Manual available on the DSCP website.

7.2.2. NM must communicate to DSCP specific subsistence needs such as low-fat dairy

products, special bread items, ice cream novelties and any dietetic items (low sodium, low-

fat, sugar-free). (T-3). NM must detail what is unique to its operation and the support

needed. (T-3). Any special requests or unusually large orders must be communicated to the

vendor. (T-3). Problems with vendors should be reported to DSCP for resolution, after

reasonable attempts to arrive at settlement have occurred with the vendor. Communication in

writing with DSCP on vendor’s performance, both positive and negative, is essential in

determining continuing contracts or future awards. Vendors must communicate with NM

and DSCP representatives during all phases of the contract award process. (T-3). It is the

prime vendor’s responsibility to communicate his terms not only to DSCP but also to NM.

(T-3). The Contractor Representative must be accessible to NM and the vendor’s customer

service must be available and easily reached by phone. (T-0). Vendor communication and

the level of service should be the same with government customers as it is with all others.

AFMAN44-144 20 JANUARY 2016 35

DSCP is responsible for explaining the contract and identifying the customer’s requirements.

DSCP is responsible for communications with all parties during the acquisition process.

DSCP must act as the customers’ advocate in communicating with the vendors and must

require vendors to adhere to the conditions and terms of the contract.

7.3. Financial Accountability. The duties of personnel purchasing subsistence will be

separated from the duties of personnel completing ration accounting so that no one individual is

responsible for both originating data (source records) and inputting/processing data. (T-3).

Therefore, individuals who issue food will not be authorized to close verify or issue/return

documents to the official inventory. (T-3). Storeroom personnel will not be responsible for

completing the NM Accounting Spreadsheet. (T-3).

7.4. Subsistence Purchasing. NM will purchase subsistence through DSCP or DVA prime

vendor contracts and local direct delivery contracts. (T-0). Small facilities with limited NM

operations may use Government Purchase Card (GPC) accounts to purchase subsistence items

needed for patient feeding. The cost of food purchased is charged to the medical sub-account of

04(X), Essential Station Messing (ESM), Military Personnel Appropriation. (Example: 5703500

320 48 562 525725). The correct ESM accounting classification number is updated annually and

is effective 1 October. A letter from the Air Force Services Activity (AFSVA), coordinated

through the AF SG Consultant Dietitian/BSC Associate Chief for Dietetics, and distributed to

MAJCOMs and MTFs indicates the updated ESM account classification number.

7.4.1. Subsistence orders are submitted according to locally established procedure. (T-3).

7.4.2. Subsistence acceptance authority is assigned to NM. (T-3). NM must designate

individuals authorized to accept or reject subsistence or supplies delivered under prime

vendor programs or other DSCP contracts. (T-3).

7.4.2.1. Designated personnel should verify the hard copy purchase order with the

vendor invoice from the driver. Ensure that products received match those ordered at

time of receipt so that the vendor’s delivery ticket may be annotated with any

discrepancies. (T-3). When discrepancies are detected upon receipt, the vendor’s invoice

will be annotated to indicate actual quantities received by striking through the listed

quantity and entering the received quantity and reasons for the differences (i.e., damaged,

short quantity, missing, substitution, high temperature, etc.). (T-3). These changes must

also be made in STORES before the STORES receipt is sent for payment. (T-3). If the

vendor substitutes more expensive food items, NM personnel should follow procedures

outlined in the prime vendor contract for resolution. The individual making the change

should initial all corrections to the distributor’s invoice. The carrier’s representative

should sign the invoice when such corrections are made. Any invoice changes must be

verified with prime vendor. When discrepancies are detected after receipt confirmation,

NM personnel should phone the distributor’s customer representative to request a one for

one replacement for the discrepant quantity.

7.4.2.1.1. Invoices must reflect only items/quantities accepted and signed for by the

NM receiving official. (T-3).

7.4.2.1.2. Invoices must be receipted through STORES DLA. (T-3).

36 AFMAN44-144 20 JANUARY 2016

7.4.2.1.3. STORES receipt prices must be used to upload data into Computrition

(Vendor receipts are used to verify items and quantity of items received, but vendor

prices are not used). (T-3).

7.4.2.1.4. Check each function in the billing chain: NM storeroom personnel, DSCP

or VA Account Manager and Contract Specialist, and Prime Vendor Billing

Department, to make sure all codes and billing/accounting information are correct.

(T-3).

7.4.2.1.4.1. Billing errors may result from many causes: invalid Department of

Defense Activity Address Code (DODAAC), incorrect Military Standard

Requisitioning and Issue Procedure (MILSTRIP) profile, TAC 3 billing address,

and/or ESM accounting classification.

7.4.2.1.4.2. The DODAAC is the unique code that identifies the NM activity. All

NM activities must have a DODAAC beginning with "FT" and followed by a

four-digit number. Codes with other two-letter prefixes, such as "FB” or "FM”

are incorrect. Questions or concerns about this code should be referred to the

MAJCOM Dietitian.

7.4.2.1.4.3. MILSTRIP PROFILES are the “ship to” address for delivering food.

The NM MILSTRIP profile must be current in the DSCP system for proper

billing and payment.

7.4.2.1.5. Each month the SF 1080, Voucher for Transfers Between Appropriations

and/or Funds, will be verified. (T-0). The SF 1080 is obtained from DFAS-

JDCBB/CO-EBS (Address: Defense Finance and Accounting Service; Attn: DFAS-

JDCBB/CO-EBS; P.O. Box 182204; Columbus, OH 43218-2204). Any billing

errors are corrected through the DSCP account manager. Procedures to verify the SF

1080 may vary from base to base. Each base must coordinate with their DSCP

account manager to determine the correct method. The typical method is as follows:

The SF 1080 will be verified with Computrition reports and vendor receipts. (T-1).

At the end of each month, the NM accountant or NCOIC will compare the amount

disbursed by DFAS to the amount of subsistence purchased as shown on the invoices.

(T-0). This is accomplished by comparing the total subsistence purchases recorded in

Computrition with total disbursements for the month. Each invoice paid will be

verified and marked if accurate payment was made. (T-0). A Memorandum for

Record will be attached to the report indicating invoices from previous months paid

during the current month and an annotation made by invoices to be paid in the next

month. Any discrepancies in amounts reimbursed by DFAS or invoices not paid

within two months will be submitted in a letter format to the regional DFAS office for

correction. (T-0). NOTE: Throughout the month the accountant may want to record

each invoice number and dollar value to facilitate reconciliation at the end of the

month. Invoices must reflect only items/quantities accepted and signed for by the

NM receiving official.

7.4.3. The subsistence GPC card in NM activities will be used for the purchase of

subsistence items only. (T-3). This card is not authorized for any other purchases. Items

other than subsistence to support the preparation or serving of foods may not be purchased

with this card. The government purchase card can typically only be used to purchase items

AFMAN44-144 20 JANUARY 2016 37

from DeCA. The NM government purchase card is for urgent clinically driven nutritional

requirements. Urgent purchases include foods for patient feeding when these foods are not

available through the prime vendor or DECA. If they are available through the prime

vendor, then the prime vendor must be used. The GPC cannot be used to purchase

subsistence from any other local sources unless approved by Corporate Food Service with

coordination with the Deputy Assistant Secretary Financial Operations.

7.4.3.1. Contact the base contracting office and request the GPC Procurement Program

Cardholder and Approving Official Account Set-Up Information application forms. Each

cardholder and each approving official must complete an application form. For address,

use the duty section address. Submit a letter of request for GPC card listing all

individuals responsible for subsistence procurement. Identify the primary approving

official as well as all designated alternates. All cardholders will receive monthly

statements of their account activity. The approving officials can view a monthly

summary statement on line. The approving official will not be a cardholder. (T-3).

7.4.3.2. Each cardholder must maintain a GPC account documentation binder IAW AFI

64-117, Air Force Government-Wide Purchase Card Program. (T-3).

7.5. Unauthorized Uses of Subsistence Items. MTF staff and visitors are not authorized to

consume unused trays, leftover food, or nourishments on inpatient care units. (T-3). Food items

purchased for use by NM activities will not be issued or given to the Pharmacy or nursing

service for making medications or coloring tube feedings. (T-3). Food items for blood sugar

testing, gastric emptying studies, etc. are purchased through their respective departments.

Pharmacy, nursing service and any other departments may purchase necessary subsistence items,

such as sugar, baking soda, cornstarch, or food coloring from DeCA or other vendors via their

own GPC accounts. Nonfood items such as charcoal and lighter fluid for NM theme meals

should be purchased with NM supply funds. (T-3). Subsistence funds and food items purchased

with subsistence funds are not used for guest meals, snacks, coffee breaks, cooking

demonstrations, parties of any type, blood donor or health promotion programs. Food items for

health promotion activities are purchased via separate health promotion GPC accounts. (T-3). If

food items for blood donor or health promotion programs are purchased by other departments

and are stored in NM, they will not be posted, included in the NM subsistence inventory, or

physically located with other subsistence. (T-3). These items will be controlled, specially

marked, and used only in support of the programs for which they were purchased. (T-3).

7.6. Perpetual Inventory. The Storeroom Manager is responsible for keeping the perpetual

inventory system of subsistence stock records and source documents for subsistence purchases

and issues. (T-3). Entries include vendor receipts and purchase invoices, GPC statements and

receipts, or AF Forms 543, Food Issue Record.

7.6.1. (Automated) . Access the Computrition online user manual for appropriate

procedures by pressing F1 while logged into Computrition. (T-3).

7.6.2. (Manual) . AF Form 542, Subsistence Stock Record, is used to maintain a perpetual

inventory of all food items in the storeroom. (T-3).

7.7. Physical Inventory.

7.7.1. A physical inventory is performed each month on one of the last three normal duty

days and is representative as of the date of the inventory (with the exception of FY close-out

38 AFMAN44-144 20 JANUARY 2016

when the inventory is performed on the last duty day of the month). (T-3). Pre-pulled

subsistence to be used for the weekend through the last calendar day must be issued on the

actual day used. Any inventory adjustment is to be posted to AF Form 546, Food Cost

Record, or NM Accounting Spreadsheet as of the date of inventory. (T-3). Post the

remaining days of the month and close out the AF Form 546 or NM Accounting Spreadsheet

on the last day of the month. The FY close-out in September should be conducted on the last

day of the fiscal year when possible; otherwise, it is taken on the last duty day and the above

procedures followed for closing out the account.

7.7.2. The MTF Commander or designee appoints a disinterested person (officer or

noncommissioned officer in grades E-7 or above) to perform a physical inventory of all food

items. (T-3). The inventory officer must be trained on their responsibilities and inventory

procedures. (T-3). This training should include directions on using the wall-to-wall

inventory method (shelf-by-shelf, top to bottom) to count and record the total quantity of

each item on hand. A NM representative will assist the inventory officer. The storeroom is

closed and no food issues are made until the inventory is completed. (T-3). Any food issues

made after the inventory are dated for the following day. (T-3). A physical count is taken of

each unissued food item on the inventory listing obtained from Computrition. (T-3). The

inventory officer delivers the completed and signed inventory listing to the Commander’s

Support Staff and NM Officer/NCOIC. (T-3).

7.7.3. Inventory Certification. After the inventory is done, the inventory officer and NM

inventory representative sign the following statement on the last page of the inventory listing:

"I certify this physical count of inventory is correct." (T-3).

7.7.4. If the physical count and the inventory records do not agree, attempt to recount the

item(s) and reconcile the differences using purchase invoices, issue logs, GPC receipts,

and/or Computrition reports. (T-3). When differences cannot be reconciled, an Inventory

Adjustment Report is prepared. (T-3).

7.7.4.1. Inventory Adjustment Report. When approved, this report is a valid accounting

document used to adjust discrepancies found during a regularly scheduled inventory.

NM will keep a copy of the approved report. (T-3).

7.7.4.1.1. The MSA officer and NM Accountant prepares the Inventory Adjustment

Report from the costed inventory listing to show actual overages and shortages by

item and the net total monetary adjustment. It must also show the total value of all

subsistence issued since the last inventory and the value of one half of one percent

(0.005) of that total. NM Storeroom personnel are not authorized to prepare this

report. (T-3).

7.7.4.1.2. NM submits the report to the squadron commander, who is authorized to

approve net dollar discrepancies of not more than one-half of one percent (0.005) of

the total dollar value of food used since the last inventory. (T-3). Food items that are

not approved for adjustment by the squadron commander as well as losses or

damages due to other than normal NM operations (fire or theft) may require Report of

Survey action by the commander.

7.7.5. Inventory Control. At the end of each quarter and the fiscal year, the dollar value of

the closing inventory, as reported on AF Form 541, Nutritional Medicine Service Subsistence

AFMAN44-144 20 JANUARY 2016 39

Cost Report, or NM Accounting Spreadsheet, will be between 15 and 30 percent of the

cumulative average monthly cost of food used for the fiscal year to date. (T-3). MTFs using

Prime Vendor for subsistence will reduce inventory levels to 2-3 days’ supply, or not more

than 15 to 30 percent of the cumulative average monthly cost of food used for the fiscal year

to date. (T-3). Optimal inventory levels must be determined locally to ensure that adequate

food is on hand/available in case of disaster or emergency situations when deliveries are

likely to be disrupted. (T-3). Additionally, it is important to review cumulative (versus

exclusively quarterly) dollar value of the closing inventory to meet monetary standards at FY

close out.

7.7.5.1. Additionally OCONUS locations may have special circumstance that preclude

strict adherence to a closing inventory value of 15-30 percent, secondary to varying costs

and transportation time, depending on availability and location of the prime vendor

utilized.

7.8. Closing a NM Activity. No less than four months prior to closing, start dropping the

inventory level to below the 25 percent level. (T-3). Adapt menus to use food in stock instead of

purchasing more food. (T-3). Gradually drop the inventory level so that two months prior to

closure, the inventory level is approximately 15 percent. At closure, transfer the last bit of

inventory to other base dining facilities. (T-3).

7.9. Issuing Subsistence.

7.9.1. (Automated) Items are issued in Computrition. (T-3). Access the Computrition

online user manual for appropriate procedures by pressing F1 while logged into

Computrition.

7.9.2. (Manual) AF Form 543 is used to issue food supplies manually. Once able to access

Computrition, transcribe all information. AF Form 543 is a source document used by the

MSA officer and NM storeroom personnel to maintain the official perpetual inventory of

food items. Storeroom personnel complete AF Form 543 for each day of the week and issue

direct delivery items on the day they are received. Perishable fresh fruits and vegetables may

be issued the day of purchase and receipt. High volume, low-cost items may be issued as

needed each day, or for a longer use period. Food items being issued should be listed by

food groups or some other internal order on the form to expedite issuing, posting, pricing,

and receiving.

7.9.2.1. The person receiving the food items from the storeroom counts and verifies food

received and signs the form in the “received” block. (T-3). If more food items are issued

than needed, return to inventory under “returned” column of form.

7.9.2.2. No later than the day following issue of food, post issues to AF Form 542

writing the balance of the item issued in column 1 as the item is posted, and the signed

forms are reviewed and checked by NM management. MSA office gets the original and a

copy; NM keeps a copy. (T-3).

7.9.2.3. The MSA office cost-extends the two copies of AF Form 543 marking column 2

of the form as each item is posted. One copy of the cost-extended form is returned to

NM for review and filing.

40 AFMAN44-144 20 JANUARY 2016

7.9.2.4. The MSA office retains on file the original cost-extended form and returns the

duplicate to NM for filing. NM retains the file for three years for audit purposes. (T-3).

7.10. Costing Subsistence Items. All MTFs use the Last-In First-Out (LIFO) costing method

for recording purchases and costing items. (T-3). With this method, the value of the inventory is

based on the last purchase price of each line item and as food items are purchased, the new unit

price, if applicable, is used to re-value the entire balance of that line item in the inventory. This

practice is designed into the automated system. (Note: First-In First-Out is still the preferred

method for rotating food items.)

7.11. Excess Cost. Excess Costs are feeding costs that exceed the monetary allowance

authorized for individual food components or needs. Examples of situations where

reimbursements are authorized include: use of operational rations (the cost of the operational

ration that exceeds actual earnings), substituted food items, unsatisfactory subsistence (spoilage

upon delivery), beverages for medical readiness exercises, and lost meals due to disaster or

exercise situations. These credits are not added to earnings, but rather subtracted from issues.

(T-3). The resulting dollar amount, Food Served, is used to calculate monetary status. (T-3).

Monetary credit is taken and annotated on the NM Accounting Spreadsheet in the excess cost

column; this is calculated into the earnings minus issues. The dollar value of issues will not

reflect any cost of subsistence items that were credited. (T-3).

7.11.1. The NM officer or diet therapy supervisor prepares a statement to support the other

income (credit), including the date and hour of the disaster, combat mission or field, alert or

medical readiness exercise. Certification of this statement is required by the MTF

Commander. (T-3).

7.12. Cashier Operations. Separation of financial duties and responsibilities in authorizing,

processing, recording and receiving cash transactions is essential to prevent loss of funds. NM

must develop a local instruction to detail how cashiering and accounting duties are separated so

as to establish adequate internal controls to prevent theft and abuse. (T-3).

7.12.1. Change Fund. DoD Financial Management Regulation 7000.14-R, Vol 5, Disbursing

Policy and Procedures, Chapter 3, Keeping and Safeguarding Public Funds, authorizes and

states how the NM Officer requests a change fund.

7.12.2. Cash Control. For A la Carte (ALACS) operations, a cash control supervisor must be

designated in writing. An adequate funds storage safe must be available to hold the change

fund, cash sales, and controlled forms. (T-3).

7.12.2.1. AF Form 2570, Nutritional Medicine Service Cash and Forms Receipt, is used

to issue the cash drawer, and AF IMT 79, Headcount Record, to the cashier as required.

The same AF Form 2570 is used by the cashier to return the cash drawer, cash collected,

and AF IMT 79 to the cash control officer after the meal. (T-3). Discrepancies are also

noted on AF IMT 79. (T-3).

7.12.3. Control of signature and cash collection forms and cash. The cash control supervisor

indicates funds and controlled forms (AF IMT 79) for turn in to MSA using AF Form 1305,

Receipt for Transfer of Cash and Vouchers, for cash collected and AF Form 1254, Register

of Cash Collection Sheets, for controlled forms used to document the transfer of

responsibility from NM to MSA. (T-3). If the forms used vary by installation, comply with

local policies.

AFMAN44-144 20 JANUARY 2016 41

7.12.3.1. The AF IMT 79 is a controlled form used to obtain the signatures of all persons

who eat in NM dining facilities at government expense (i.e., ESM), except inpatients.

The AF IMT 79 is also used to collect and record all funds of cash paying customers.

The designated NM representative, who must be a government employee, keeps a

separate file of completed AF IMT 79 forms in numerical order by serial number. This

file must be physically checked at least once each month to see that all forms are

accounted for by number. (T-3). No two AF IMT 79 forms bear the same number in the

same fiscal year. All numbered and unused forms must be kept in a locked safe. (T-3).

The MSA clerk furnishes the NM representative as many numbered AF IMT 79 forms as

may be required. The AF IMT 79 forms issued to NM are tracked on AF Form 1254 by

MSA. (T-3). Completed AF IMT 79 forms are turned in by the NM cash control

supervisor by listing the serial numbers on the same AF Form 1305 used to turn in AF

IMT 79 forms and cash to MSA.

7.12.4. Cash and Forms turn in to MSA. All cash collected and AF IMT 79 forms used must

be turned in to the MSA office daily, excluding weekends. (T-3). However, if the storage

limit on the safe/funds storage container is inadequate to support the amount of cash

collected over a 2 or 3 day weekend, make arrangements with the MSA office to turn in

excess cash to the MSA office during the weekend period, or request an increase, through

Finance, in the amount of funds the safe/funds storage container can store.

7.12.4.1. Cash deposit paperwork (AF Form 544, Nutritional Medicine Daily Facility

Summary Report, AF Form 1305, and AF Form 2570) must be done on a daily basis,

even if the money must be held over the weekend. (T-3).

7.12.5. ALACS Cash Register Operations. Cash registers are used with the capacity to

identify ESM diners by their last four social security numbers; record meal charges; produce

daily cumulative reports of total charges to each social security number; calculate discount

and standard meal prices; receive cash; record diner head count by category, including

transient patients, inpatients eating in the dining facility, and second servings from ESM

customers; produce both patient and dining facility food consumption reports; and record

totals for Food Service Operating Expenses collected. Care must be taken that the cash

registers are correctly programmed to both calculate and charge cash patrons the standard,

with surcharge rate as well as the discount rate, and correctly total the surcharges from each

meal period. See section 6.13. ALACS Recipe Pricing Operations, for additional information

on standard and discount rates.

7.12.5.1. The DoD subsistence surcharge (operating expense) is proportionately divided

between the AF Military Personnel Appropriation (MPA) and the Defense Health

Program (DHP) O&M appropriation based on the percentage of the MTF dining hall’s

military and civilian manpower authorizations (per the Unit Manning Document). MTF

military personnel are funded by the AF MPA and civilians are funded by the DHP O&M

appropriation. MTF MSA officers will proportionately divide the surcharge accordingly

with the start of each FY. (T-3). For example, if the FY surcharge collected is $100 and

the MTF dining hall manpower authorizations are three military and seven civilian

personnel, then the proportionate amount to deposit to MPA is $30 and the amount to

deposit to the DHP O&M is $70 (e.g., out of 10 employees, 30 percent are military and

70 percent are civilian, therefore $100 would be divided respectively).

42 AFMAN44-144 20 JANUARY 2016

7.12.5.2. Cash register maintenance contracts are established and adequate supplies of

tapes and ribbons are procured locally through Medical Logistics. (T-3).

7.12.5.3. Cashiers must offer all customers a receipt for their purchases. (T-3).

7.12.6. Subsistence Credit Allowance Management System (SCAMS) Cashier Operations.

In SCAMS operations, all diners in a government dining facility, except ambulatory and

transient patients, sign for meals. The cashier verifies the diner's identification. In overseas

areas, authorized medical facility local national employees will pay for meals according to

the Status of Forces Agreement (SOFA) for that country. (T-0). Local disaster plans may

address use of personal checks and/or lost meals due to disaster situations.

7.12.6.1. Meal rates at appropriated fund facilities using SCAMS. Meal rates at SCAMS

facilities are established by the Office of Under Secretary of Defense (Comptroller).

Meal rates are posted annually effective 1 January and can be downloaded from Tab G of

the Department of Defense FY Reimbursable Rates table,

http://comptroller.defense.gov/rates/. This table also describes who is eligible for the

standard or discount rate.

7.12.6.2. All non-ESM persons entering the dining facility must pay the posted price of

the meal being served, regardless of the type of meal items or quantity selected. (T-3).

Some small volume feeding overseas facilities do not have cash registers and use the AF

IMT 79, Headcount Record, to record patron meals. Separate AF IMT 79 forms are used

for cash and ESM diners. (T-3).

7.12.6.3. The cashier ensures the AF IMT 79 forms are completed daily for each meal

period. (T-3). A separate AF IMT 79 is used for non-U.S. citizen civilian employees

overseas who are allowed to eat in the dining facility. (T-3). Use a separate AF IMT 79

for breakfast, lunch, and dinner. (T-3). These forms will not be "carried over" from one

meal to another. Therefore, in facilities where an authorized change fund is allotted for

both dollars and the local currency, three AF IMT 79 forms are issued per meal (one for

meal card holders, one for dollars, and one for local currency). (T-3).

7.12.6.4. Air Force Reserve members must present verification of eligibility for ESM

meals (reserve active duty orders or AF Form 40a, Record of Individual Inactive Duty

Training) while on active duty training or inactive duty for training, sign AF IMT 79 as

required, and write their names and last four social security numbers legibly on the forms.

(T-3). NM will make a copy of the member’s orders and turn in copies to MSA with the

AF IMT 79s for the day. (T-3). AD and Reserve members who receive the subsistence

portion of per diem are not authorized to subsist at government expense and must pay for

their meals. (T-3). When a guard or reserve unit member does not receive the subsistence

portion of per diem, they do not pay for their meals, but instead sign a separate AF Form

79 (separated by unit). (T-3). Note: Billing may be required by MSA.

7.12.6.5. After the meal, the NM supervisor verifies entries on the AF IMT 79, signs the

form, and then transfers the number of meals for each different category onto the

appropriate entries in the NM Accounting Spreadsheet (automated) and AF Form 544.

(T-3).

7.12.6.6. When the amount of cash collected varies from the number of signatures and

total amount due, the supervisor investigates and states the explanation for overages or

AFMAN44-144 20 JANUARY 2016 43

shortages on AF IMT 79. (T-3). Include the name(s) of the cashier(s) during the meal.

(T-3). If no reason for the cash variance is apparent, state that there is no apparent reason

for the cash variance. (T-3). NMs should establish local policies and procedures to track

cashier overages and shortages so corrective action or training can be initiated.

7.12.6.7. The completed AF IMT 79 forms and collected cash are delivered to the MSA

officer at least once each normal duty day. The MSA officer will, upon receipt of

completed AF IMT 79 forms, and the cash from the NM cash control supervisor, verify

the cash receipts against the total amount of cash received. (T-3).

7.12.6.8. Small volume feeding facilities will use Computrition to track inventory, as

well as all purchases and requisitions. (T-3). The NM Accounting Spreadsheet

(automated) is used to record daily earnings, issues, and purchases, as well as all relevant

patient feeding activities (APV/SDS) and patient bed days.

7.12.6.8.1. In the event the computer systems were down for an extended period of

time, the SCAMS facility would utilize standardized AF Form processes (i.e., AF

Form 542, AF Form 543, AF Form 544, and AF Form 541) to track earnings and

issues until appropriate entries could be made in the NM Accounting Spreadsheet or

Computrition, once automated operations resumed. (T-3).

7.13. Eligibility and Identification of Diners. DOD 1338.1 0-M, Manual for the Department

of Defense Food Service Program, AFI 41-115, Authorized Health Care and Health Care

Benefits in the Military Health Services System, and AFH 41-114, Military Health Services

System Matrix, state who is eligible for medical care in AF medical facilities, prescribe the extent

of care allowed, provide guidance for care, and delineate who pays standard and discount meal

rates (see Attachment 3). Meal rates are published annually by the Office of Under Secretary of

Defense (Comptroller) and are typically released by HQ USAF/SG3 to resource management

officers in December, with an effective date of 1 January. All meal rate prices must be posted at

the dining facility entrance or serving areas. All MTF staff members must pay for all food

consumed.

7.13.1. Transient patient. Transient patients in the aeromedical evacuation system or Non-

Medical Attendants (NMAs) do not pay or sign for meals. They are identified by the patient

identification wristband or IAW local procedures. A patient ceases to be a transient patient

when admitted to a MTF. The number of transient patients at each meal is recorded as a

Remain Over Night (RON) patient on the NM Accounting Spreadsheet (automated) and AF

Form 544, Nutritional Medicine Daily Facility Summary Report (manual). (T-3). Breakfast

meals are calculated to receive .20 meal credit; lunch and dinner, .40 meal credit. (T-3).

7.13.2. Nonmedical attendant (NMA). The nonmedical attendant of a hospitalized patient

pays the appropriate charges for all meals consumed.

7.13.3. Essential Station Messing (ESM). ESM diners are enlisted members authorized to eat

at government expense. Medical enlisted personnel and airmen assigned to the MTF present

their DoD Common Access Card (CAC) Identification Card. (T-3). Enlisted personnel in

TDY status must show valid orders and their DoD CAC Identification Card. (T-3). Follow

installation-specific guidance for identifying eligible personnel as appropriate.

7.13.3.1. The OIC/NCOIC of NM validates ESM diners using last name and last four of

Social Security Numbers for identification and spot check signature/cashier records to

44 AFMAN44-144 20 JANUARY 2016

ensure that only authorized personnel are subsisting at government expense. (T-3). A

current listing of ESM diners from the base Force Support Squadron should be received

and reviewed at least monthly.

7.13.4. Inpatients and ambulatory procedures visit (APV)/same day surgery (SDS).

Inpatients and APV/SDS patients are identified by nursing staff using AF Form 1094 or

through the Essentris-Computrition interface. (T-3).

7.13.5. Outpatients. Outpatients in the MTF for treatment may purchase meals from vending

machines or directly from NM as guests.

7.13.6. Wounded Warrior (WW) Meals. In accordance with the National Defense

Authorization Act for Fiscal Year 2009, section 602, MTFs provide meals at no cost (and no

surcharge) to certain injured members of the Armed Forces while receiving healthcare

services for an injury, illness, or disease incurred in support of OPERATION IRAQI

FREEDOM, OPERATION ENDURING FREEDOM, or any other operation or area

designated by the Secretary of Defense. (T-0). Healthcare services include medical

recuperation or therapy or other continuous care as an inpatient or outpatient.

7.13.6.1. Wounded Warriors (WW) will present DoD Form 714, Meal Card, indicating

that member is a WW entitled to a meal free of charge. (T-0). In addition, WW’s must

present CAC Military Identification Card. (T-3).

7.13.6.1.1. For bases that do not have a local WW Liaison Office or Coordinator to

issue WW meal card (DoD Form 714, Meal Card), NM will establish a local

guidance to properly identify eligible WWs to help prevent fraud, waste and abuse of

this privilege. (T-3).

7.13.6.2. The NM cashier will process the WW’s meal at no cost and input meal

purchase into the cash register system IAW local procedures. (T-3).

7.13.6.3. WW will sign a separate AF IMT 79 entitled, “Wounded Warrior”. (T-3). AF

IMT 79 will include at a minimum WW name, rank, unit of assignment, and contact

information. (T-3).

7.13.6.4. The number of WW meals served will be entered daily as a wounded warrior

into the AF Accounting Spreadsheet. (T-3).

7.13.6.5. A tally of total WW meals will be tracked on the AF Accounting Spreadsheet

and NM will provide monthly cost and service summaries per local guidance obtained

from AFSVA. (T-3).

7.13.6.6. NM will advertise the WW meal program by posting the Assistant Secretary of

Defense for Health Affairs Memorandum dated 4 February 2009 on bulletin board(s) in

the NM department visible to patrons. (T-0). The memorandum can be located at

http://www.tricare.mil/ocfo/_docs/20090204%20Permanent%20Waiver%20of%20

Meal%20Surcharge.PDF.

7.13.7. Non-admitted meals (NAMs). This is a category of meal accounting for designated

outpatients in the MTF. The Diet Therapist will annotate on AF Form 2573, Weighted Diet

Census. (T-3). Follow local infection control policy when providing food to non-admitted

patients. (T-3).

AFMAN44-144 20 JANUARY 2016 45

7.13.7.1. Outpatients in the MTF for treatment (not APV or SDS) for greater than 4

hours (i.e. chemotherapy clinic, dialysis clinic, emergency room) who by virtue of their

care cannot leave the area to obtain food or beverage may be provided

nourishment/meals. Meals/nourishments provided are accounted for under “non-

admitted meals” on the accounting spreadsheet. NAM eligible outpatients do not visit the

dining facility to obtain a “free” meal. The NDAA 2012 provision of food guidance can

be found at: http://www.gpo.gov/fdsys/pkg/BILLS-112hr1540enr/pdf/BILLS-

112hr1540enr.pdf. The guidance can be located on page 175, section 704, 0178b

(Provision of food to certain members and dependents not receiving inpatient care in

military medical treatment facilities).

7.13.7.2. Parents (non-patients) who are required by the physician to stay on the pediatric

inpatient unit to be with their child (the patient) may be served meals on the unit. Meals

are accounted for under “non-admitted meals” on the accounting spreadsheet. (T-3).

7.13.7.3. Breastfeeding mothers (non-patients) of infants admitted to the hospital may

receive a tray in place of the infant. Meal cost is tracked on the accounting spreadsheet in

the “non-admitted meals” column.

7.13.7.4. When requesting food and beverages from the MTF’s Food Service

Department it is important that: (1) communication is accomplished in a timely manner to

take care of the patient’s nutritional needs, (2) dietary restrictions are addressed at the

time the order is placed, and (3) food and beverages are provided in a timely manner in

accordance with the MTF’s routine food service procedures.

7.14. ALACS Recipe Pricing Operations. In ALACS each recipe item is priced and sold on

an individual item basis. Computerized menu pricing reports such as the Computrition Recipe

Price Report must be available. (T-3). Each recipe cost that is not available from these programs

must be manually calculated, per DoD guidance: When using an “a la carte” menu, the price of

every item on the menu shall be established at 133 percent (surcharge) of the food cost (i.e., the

cost of unprepared food multiplied by a factor of 1.33). The following category of diners will be

charged a discount price. (T-3). This discount price is the menu cost minus the 33% surcharge.

The discount rate shall not be charged to:

(a) spouses and other dependents of enlisted personnel in pay grades E-1 through E-4.

(b) members of organized nonprofit youth groups sponsored at either the national or local level

and permitted to eat in the general dining facility by the Commanding Officer of the installation.

Such groups include: Civil Air Patrol, Junior ROTC and Scouting units.

portion of per diem and who are either: (1) Performing duty on a U.S. Government vessel, (2) On

field duty, (3) In a group travel status, or (4) Included in essential unit messing (EUM) as defined

in the JFTR, Volume 1.

(d) officers, enlisted members, and federal employees who are not receiving the meal portion of

per diem, and who are on a U.S. Government aircraft on official duty either as a passenger or as

a crew member engaged in flight operations.

(e) officers, enlisted members, and federal employees on Joint Task Force operations other than

training at temporary U.S. installations, or using temporary dining facilities.

In addition, when calculating the base menu item cost, an additional 20% condiment fee may be

added to the basic cost per portion of all items served in appropriated fund food activities. This

46 AFMAN44-144 20 JANUARY 2016

addition is intended to cover condiments, and items that are not recipe ingredients (nonstick

spray, fryer oil), and food preparation losses from spillage, burning, discarded, etc. Ideally this

variable percent should be adjusted per menu item. As an example, if French Fries cost $0.50

per serving from the prime vendor, a 33% surcharge is added. In addition, since this is a non-

ready-to-eat food (needs to be fried), a 20% condiment charge is added, making the cost to the

patron $0.80. Conversely, a pre-portioned ready-to-eat food item such as an 8 oz carton of milk

should have a surcharge of 33% (per DoD ALL menu items are assessed surcharge) and

condiment additive of 0% since it is ready to eat.

7.14.1. ALACS facilities are encouraged to round menu item prices at the registers to the

nearest $0.05.

7.15. Special Feeding Circumstances. Responsibilities for control measures, when feeding

under disaster and combat conditions or during field, alert, and medical readiness exercises, are

the same as those under normal circumstances. Personnel who receive monetary allowance for

subsistence must pay for their meals, including paying for operational meals such as MREs. In

normal NM management procedures apply during disasters, in combat areas, and during field,

alert or medical readiness exercises as often as possible. Special cashier procedures may have to

be instituted during disaster or emergency conditions. The installation commander provides the

MTF Commander with a statement (verbal, followed in writing) that emergency or disaster

conditions prevail and that it is essential to furnish food to persons other than those normally

allowed. (T-3). Those persons able to pay for meals sign AF IMT 79 if required, and pay

according to Attachment 3 of this Manual. (T-3). Those persons unable to pay for meals sign a

separate AF IMT 79. (T-3). The diet therapy supervisor or other specified person writes the

name of the group of persons being fed on the AF IMT 79 above the title. (T-3). If it is not

feasible to obtain signatures, as in the case where food support is provided to another civilian

hospital, the NM officer certifies the number of meals furnished on a separate AF IMT 79 and

includes the statement: “I certify that (number of meals) were provided to (the name hospital) in

(location) due to (situation, such as hurricane) for (the meal period, meal date).” (T-3). The

number of meals is included on AF Form 544 and NM Accounting Spreadsheet. (T-3). Credit is

taken for all meals. (T-3). The MSA officer and NM accountant maintains documentation to

prove entries on AF IMT 79 and 544 and NM Accounting Spreadsheet. (T-3). If feasible, the

MSA officer bills the appropriate agency for the costs of meals provided.

7.16. NM Ration Accounting. For accurate NM financial reports, NM accounting parameters

must be accurate and up to date, whether calculated on the AF Accounting Spreadsheet or

manually. (T-3).

7.16.1. A ration is the quantity of nutritionally adequate food required to subsist or feed one

person for one day.

7.16.2. The Food Cost Index is a DoD prescribed list of food components and quantities that

represent the allowance for fifty-five standard ration food items, which is used to compute

the Basic Daily Food Allowance (BDFA). (T-3).

7.16.3. The BDFA is a prescribed quantity of food, as defined by components and monetary

value, required to provide a nutritionally adequate diet for one person for one day.

7.16.3.1. (Automated) . The MTF BDFA is calculated monthly on the NM Accounting

Spreadsheet using the most current Food Cost Index. (T-3). The BDFA can also be

AFMAN44-144 20 JANUARY 2016 47

calculated using the Joint Culinary Center For Excellence Quartermaster Website at

http://www.quartermaster.army.mil/jccoe/operations_directorate/quad/BDFA/bdfa

_main.html. The template built into the NM Accounting Spreadsheet must follow the

Food Cost Index obtained from the Defense Logistics Agency. (T-3). For correct

computation of this allowance, using prime vendor contracts or DeCA, the exact

subsistence items referred to by the National Stock Number (NSN) need to be verified.

(T-0). When verifying items and calculating the BDFA, food substitutions may only be

used if the exact food item listed by the stock number is unavailable through prime

vendor. (T-3). Even if the item is not used, if it is available, it must be priced for BDFA

calculation. Do not substitute higher cost items not intended for use to artificially raise

the BDFA, and do not substitute higher cost items because of personal preference. (T-3).

7.16.4. Patient Basic Daily Food Allowance (Patient BDFA) is the MTF BDFA with an

added 15 percent supplemental allowance (Patient Supplemental Percentage) to help defray

the cost of bulk nourishments. The Patient BDFA is only used to calculate patient meal day

earnings. Only one Patient BDFA applies for the full calendar month.

7.16.4.1. (Automated) Use NM Accounting Spreadsheet to compute Patient BDFA for

patient meal days served each day. (T-3).

7.16.5. Small Volume Feeding Allowance/Percentage. NM activities using SCAMS and

serving less than 100 average daily meal days for both patient and dining facility patron

rations are authorized an additional supplemental allowance of 15 percent of the MTF BDFA

in order to adjust for the increased costs of feeding a smaller number of people. (T-3). This

eligibility is determined at the end of each month using the previous months average daily

meal days, and is applied to ESM and SCAMS dining facility patrons only. It is not

authorized for ALACS cash sales. (T-3). If allowed, the 15 percent supplemental allowance

is used to figure the next month’s MTF BDFA. As an example, if calculating the small

volume allowance for August, you would take the total meal days for July, divide by 31

(days in month), if the total is less than 100, then the allowance is authorized.

7.16.6. Therapeutic In-flight Meal (TIM) Allowance. A special monetary allowance equal to

80 percent of the MTF BDFA is authorized for each TIM furnished by the NM activity for

aeromedical evacuation patients to be consumed in flight. Additional guidance may be found

in AFI 41-301, Worldwide Aeromedical Evacuation System, and AFI 41-307, Aeromedical

Evacuation Patient Considerations and Standards of Care.

7.16.7. Holiday and Special Meal Percentages/Allowances. An additional meal allowance is

permitted for certain federal holidays, typically Christmas and Thanksgiving, the Air Force

birthday, and Airmen appreciation meals. The extra earnings allowed for holidays and

special meals are designed to recoup additional costs incurred, to include serving items in the

dining facility to ESM patrons at all facilities and cash patrons at SCAMS facilities, as well

as for holiday meal enhancements for inpatients (e.g., nut cups, ice cream, cake, candy, etc.).

For these meals, an additional 25% meal allowance is permitted. For Airman appreciation

meals, an additional 15% is allowed. Christmas and Thanksgiving holiday meals must be

served at the lunch meal. If holiday or special meals are served on dates other than the

holiday, the Accounting Spreadsheet manager should be informed. There must be a special

menu planned and served to qualify for the additional allowance. A la Carte facilities do not

48 AFMAN44-144 20 JANUARY 2016

receive an additional 25% on cash customers as any additional cost associated should be

calculated into the cost of the food.

7.16.7.1. (Automated) NM Accounting Spreadsheet automatically calculates the

additional 25 percent holiday lunch percentage for Thanksgiving and Christmas. To

calculate extra earnings for other holidays and special meals in SCAMS facilities, the

number of ESM lunch meals served is added to the number of cash patron lunch meals

served and this is then multiplied by 25 percent (or 15 percent for airman appreciation

meals) to equal the additional number of meal days. This additional number of meal days

multiplied by the current MTF BDFA will equal the amount of additional earnings for the

holiday lunch meal. For ALACS facilities the same procedure is followed, only the

additional meal day earnings for other federal holidays is determined only by the number

of ESM customers, and patients served.

7.16.8. Occupied Bed Day refers to the number of inpatients subsisting in the MTF and

equals beds occupied minus bassinets from the Admission and Disposition Recapitulation

Report.

7.16.9. A Meal Day is a value in which the number of meals is weighted by a predetermined

percentage (IAW DOD 1338.10-M) to balance the cost and attendance variances between the

meals. The number of meal days for a given day is figured by multiplying the number of

breakfast, lunch, and dinner meals served by the factored percentages of 20, 40, and 40

percent, respectively, and totaling the results. TIMs are valued at 80 percent, APV/SDS

meals at 40 percent, holiday meals at 65 percent, and, if served, midnight meal at 20 percent.

If APV patrons utilize the dining facility for breakfast, they are valued at 20 percent of the

BDFA. Beginning in Fiscal Year 2016, the number of meal days for a given day is figured

by multiplying the number of breakfast, lunch, and dinner meals served by the factored

percentages of 25, 40, and 35 percent, respectively, and totaling the results.

7.16.10. Patient Meal Days are obtained by multiplying the occupied bed days times the

appropriate meal factors.

7.16.11. ESM Meal Days are obtained by multiplying the number of ESM patrons multiplied

by the appropriate meal factors.

7.16.12. Cash Patron Meal Days are obtained by multiplying the number of cash customers

times the appropriate meal factors.

7.17. Subsistence Account Reporting and Management.

7.17.1. AF Forms 544, Rations Earning Record, the NM Accounting Spreadsheet and

Computrition are used to assist NM managers and the MSA Officer in overseeing the

subsistence account, inventory value, earnings and collections. AF Form 544 or electronic

equivalent, and the NM Accounting Spreadsheet will be made available to the MSA Officer

to facilitate daily, monthly, quarterly, and end of fiscal year oversight of subsistence

accounting. (T-3). NM operations are encouraged to place electronic versions of the 544,

and the NM Accounting Spreadsheet on a shared drive, with limited access to key personnel

within NM and MSA.

7.17.1.1. (Automated) . AF Form 544 and the NM Accounting Spreadsheet have all of

the information needed to monitor key financial indicators in NM.

AFMAN44-144 20 JANUARY 2016 49

7.17.1.1.1. The Computrition Inventory Movement Summary Report provides

detailed information pertaining to food purchases. The report can be sorted by food

categories or dollar value. The verified total from this report should be compared to

the cost of food purchased for the day from invoices received.

7.17.1.1.2. The Computrition Inventory Cost Report lists inventory items by

category, NSN, vendor issue unit, issue cost, quantity on hand, and value of current

inventory. This value is entered on the NM Accounting Spreadsheet.

7.17.1.1.3. AF Form 544 is used to record the number of meals served in MTFs. The

information on AF Form 544 is used as a guide for determining the number of meals

to prepare, deciding on quantities of food to purchase, store and issue, helping to

control food costs, and providing cumulative daily, monthly, quarterly, and yearly

cost data. The form covers categories of inpatients and categories of diners in the

dining facility, and TIMs. A separate form is used daily and then taken to the MSA

office. Note: At minimum a copy of the AF Form 544 or electronic equivalent

showing the categories of diners, ration earnings by meal, and daily food cost data

will be submitted to MSA daily, or by the first duty day following a weekend. (T-3).

The form will be signed by the NCOIC, Nutritional Medicine, or equivalent, and the

MSA officer. Both MSA and NM file a copy. (T-3).

7.17.1.2. (Manual) . The following three manual cost data records and financial reports

may be used in NM and the MSA office to determine financial status. Follow specific

instructions on forms for completion. Manual accounting will only be accomplished

when computer access and the NM Accounting Spreadsheet are unavailable. (T-3). This

would not include short term system failures, as the NM Accounting Spreadsheet can be

updated when systems come back online.

7.17.1.2.1. AF Form 544 is completed by following the instructions on the back of

the form.

7.17.1.2.2. When documenting manually, AF Form 541 is used to provide quarterly

and cumulative fiscal year summary data on food purchased in NM. It shows the

financial status operating under the SCAMS management system. The AF Form 541

is only used in facilities performing manual accounting. If required, the AF Form 541

is completed quarterly by the MSA Officer using data provided by NM on AF Forms

544, and 546.

7.17.1.2.3. AF Form 546 provides an overview of daily financial transactions and

current monthly cumulative totals. AF Form 546 will be provided to the MSA

Officer each month, on a date mutually agreed upon. (T-3).

7.17.1.3. Inpatient Diet Census. Workload figures for the number of trays served to

patients on the nursing units and the number and types of therapeutic diets served will be

documented on AF Form 2573, Diet Census, or electronic substitute, once daily, using

breakfast, lunch, or dinner data (typically lunch is used). (T-3). Additional instructions

are printed on the reverse side of the form. NM gives the workload figures and weighted

diet census from AF Form 2573 to the MSA Office per local guidance. The AF Form

2573 provides critical manpower data and should be reviewed monthly by NM leadership

to ensure accuracy.

50 AFMAN44-144 20 JANUARY 2016

7.17.1.4. Air Force Medical Operations Agency (AFMOA) Reporting. On a monthly

basis, MTFs with food service operations will submit a spreadsheet including the

information/data in Attachment 4 to their MTF MSA Office and Functional Manager. (T-

3). The MAJCOM Functional Manager (MFM) will submit a consolidated report (Excel

spreadsheet), for their MAJCOM, by MTF, to the AFMOA Uniform Business Office

IAW AFI 41-120, Medical Resource Management Operations. (T-3). The consolidated

MAJCOM report will be submitted to AFMOA by the MFM by no later than close of

business on the 5th calendar day following the last day of the month. (T-3). Example, the

April report will be submitted by no later than 5 May. (T-3).

7.17.2. Subsistence Account Management. Primary indicators which evaluate the financial

status of the NM operation are: earnings less cost of food served, earnings minus purchases,

inventory level, and periodic inventory adjustment.

7.17.2.1. Financial Parameters. The financial status of the NM subsistence account is

measured using food issues adjusted for spoilage and supplemental/other income, which

is referred to as cost of food served. The status of earnings minus cost of food served

must not exceed plus or minus 5 percent of the average monthly ration earnings at the end

of each of the first three quarters of the fiscal year, as annotated on the AF Accounting

Spreadsheet. At the end of the fiscal year, earnings minus cost of food served must not

be more than $100.00 or plus or minus 2 percent of the average monthly credit earnings,

whichever is greater. (T-3). When calculating the 5 percent for the quarter or the 2

percent for the end of fiscal year, always use fiscal year to-date figures. As an example,

at the end of March take the total earnings fiscal year to-date and divide by 6 to get the

monthly average, then multiply that number by 5% or 0.05 to get the plus or minus range.

Your fiscal year to-date earnings, minus cost of food served, must fall within that range.

7.17.2.2. Fiscal Year Close-out. If, at the end of the fiscal year, the earnings minus cost

of food served on the NM Accounting Spreadsheet exceeds (plus or minus) 2 percent of

the average monthly earnings (total earnings, fiscal year to date, divided by 12), the MTF

Commander may consider initiating a Report of Survey action.

7.17.2.3. Transferring a Subsistence Account when Food Served Exceeds Credit

Earnings. A report of survey is initiated when a NM officer or NCOIC (when no dietitian

is assigned), accepts a subsistence account where the authorized parameters for the

current quarter have not been met. The officer who writes the report of survey

determines if there is an excessive loss, the cause of the loss, and any financial liability.

If financial liability is found, the commander can take disciplinary action. If the

investigation shows an excessive loss, the MTF commander may request MAJCOM/SG

authority to over purchase at the end of the subsequent fiscal quarters and at the end of

the fiscal year, that portion of the loss that exceeds 2 percent of the monthly monetary

credit earnings. The request must show that the MTF cannot absorb the loss over a

period of 3 months or by the end of the fiscal year unless it reduces food services or menu

quality to the point where it would harm the morale and welfare of the subsisting patients

and enlisted personnel.

7.17.2.4. Nutritional Medicine Service Oversight Checklist can be found at Attachment

AFMAN44-144 20 JANUARY 2016 51

Chapter 8

PROCEDURES FOR MEDICAL FACILITIES SUPPORTED BY BASE FOOD

SERVICE AND DIETETIC SHARING AGREEMENTS

8.1. Procedures for MTFs supported by Base Food Service.

8.1.1. MTF Commander or designated NM representative responsibilities:

8.1.1.1. In cooperation with the Base Food Service activity, develops and maintains a

written list of personnel who may certify meal requests. (T-3).

8.1.1.2. Ensures that a letter of agreement outlining the responsibilities of both Base

Food Service and NM personnel are on file with both activities. Reviews the agreement

annually or whenever changes are indicated. (T-3).

8.1.1.3. Arranges for Nursing Service personnel to complete an original and one copy of

the AF Form 1094 for each meal. (T-3).

8.1.1.4. Arranges for an enclosed vehicle to transport NM personnel and supplies to Base

Food Service and back three times daily, at a minimum. The closed vehicle will be used

for transporting patient meal trays and nourishments from Base Food Service to the MTF

and back. (T-3).

8.1.1.5. Ensures that an appropriate healthcare provider prescribes any diets and

supplemental feedings. Per local guidance, NM in coordination with Medical Logistics

personnel, purchase enteral feedings. (T-3).

8.1.1.6. Ensures food items and meals are used only for patient feeding. (T-3).

8.1.1.7. Coordinates in advance the number and types of meals required and arranges

pickup times with the Base Food Service Supervisor. Prepares a separate (by meal

period) request for meals on AF IMT 79. Prepares, or assists NM personnel with meal

preparation. (T-3).

8.1.1.8. Notifies Base Food Service Supervisor in advance, or as soon as possible, when

menu items cannot be used for therapeutic diets and specifies substitutes. (T-3).

Substitute items must not cause the total cost of meals for patients to exceed the total

meal rate allowance. (T-3).

8.1.1.9. Assigns an individual to pick up meals, serve meals to patients in the MTF, and

return soiled dishes and equipment to Base Food Service. (T-3).

8.1.1.10. Establishes a medical sub-account and purchases special patient feeding items,

such as crackers, juice, baby food, and dietetic foods. (T-3). See paragraphs 6.3.3 and 6.5

on medical subsistence funds and procedures for purchasing food using a GPC account.

8.1.1.11. Accounts for meals served. Prepare duplicate copies of AF Form 3516, Food

Service Inventory Transfer Receipt. (T-3). For Meals Ready to Eat (MREs) transfer, use

AF Form 28, War Reserve Materiel (WRM) Ration Report, obtained from the Base Food

Service for each meal period according to instructions on the form. NOTE: Do not cost

out each menu item or the total cost of the meal. For each meal, attach the original AF

IMT 79 to a copy of AF Form 1094. (T-3). Base Food Service retains these forms for

52 AFMAN44-144 20 JANUARY 2016

audit purposes. AF Form 3516 will reflect the food items for meals and between-meal

feedings. (T-3). The Admission & Disposition list should not be used to request meals,

but should be used as a check to make sure that meals and nourishments requested are

appropriate given the number of patients admitted.

8.1.1.12. Uses AF Form 1741 to record food likes and dislikes and any food allergies for

every patient requiring meals. Include therapeutic meal patterns or substitute as required

for menu writing purposes and meal ticket preparation. (T-3).

8.1.1.13. Provides appropriate patient tray service. (T-3). The use of disposable

tableware should be minimized. If disposable dishes must be used, an insulated, stacking

patient tray delivery system is recommended to best maintain the temperature of hot and

cold foods.

8.1.1.14. Ensures that an inpatient selective menu, based on the Base Food Service

menu, is prepared in advance for patients. (T-3).

8.1.1.15. Ensures that sufficient equipment is available to prepare and/or hold foods at

the proper temperatures for food quality and safety. (T-3).

8.1.2. Base Food Service Officer or designated representative responsibilities:

8.1.2.1. Provides the NCOIC, NM, with the menu for the base dining facility at least

three days in advance and notifies the NCOIC of any menu changes at least 24 hours in

advance. Works with the NCOIC, NM, to offer at least two entree choices not served at

the previous meal. Works with NM diet therapist to determine an appropriate substitute

for therapeutic diets when regular menu items are not suitable.

8.1.2.2. Calculates and receives the appropriate earnings for reimbursement for meals

provided. Each meal provided is counted as an ESM customer. Ensures the cost of food

issued for patient feeding does not exceed the BDFA plus 15 percent. Retains the

original AF IMT 79 with attached copy of AF Form 1094.

8.1.2.3. Coordinates the number and types of meals. (T-3). Reviews certified meal

requests. (T-3). Prepares and issues regular meals. (T-3). Provides portion control

condiments for patient feeding on a "by-meal" basis. (T-3).

8.1.2.4. Provides NM personnel with a designated parking space and a work area to

assemble trays and prepare therapeutic diet food; NM section/work area should be

segregated as much as possible from Services dining and serving areas. (T-3).

8.1.2.4.1. Provides NM personnel with adequate, secure storage space for subsistence

and supplies to prevent pilferage and misappropriated use by unauthorized personnel

if available. (T-3).

8.1.2.5. Provides warewashing support area to NM activities without warewashing

facilities. (T-3).

8.2. Dietetic Sharing Agreements.

8.2.1. The MTF Commander or designee coordinates dietetic sharing agreements with the

MAJCOM Dietitian. (T-3).

AFMAN44-144 20 JANUARY 2016 53

8.2.2. The MAJCOM Dietitian reviews all sharing agreements to ensure they include all

appropriate Process Improvement programs and internal controls demonstrating services are

provided in accordance with the sharing agreement. (T-3). See Attachment 5, SAMPLE

MOA.

8.2.3. Sharing agreements must specify responsibilities and procedures. (T-3). Examples of

services available include:

8.2.4. Inpatient clinical dietetics services.

8.2.4.1. Basic, intermediate, complex, and extensive nutritional care.

8.2.4.2. Nutrition screening, assessment, and reassessment.

8.2.4.3. Use of MNT evidence-based guides for practice, protocols, and clinical care

guidelines.

8.2.5. Inpatient and outpatient consultation.

8.2.5.1. Use of SF 513 for inpatient consultation requests, or electronic/MTF-equivalent.

8.2.5.2. Use of approved form for outpatient individual and group diet consultations and

follow-up requests.

8.2.6. Patient meal service.

8.2.6.1. Meal services to include: trays, menus, ordering diets, meal service, delivering

and returning trays, and providing nourishments to patients.

8.2.7. Outcome measures and Process Improvement.

8.2.7.1. Data collection, analysis, and implementation procedures to continuously

improve quality of care and measure and monitor performance and outcomes.

8.2.7.2. Standards for patient satisfaction, tray accuracy, and quality of nutrition care.

8.2.8. Internal controls to ensure patients receive care at a standard comparable to those

received by patients at a larger AF MTF and in accordance with this AFMAN.

54 AFMAN44-144 20 JANUARY 2016

Chapter 9

CONSULTANT SERVICES

9.1. Purpose. The purpose of the AF Dietetic Consultant Program is to support the AFMS

mission through efficient NM operations that provide quality services. Consultant services are

available at various levels of operations. The Consultant Dietitian advises the AFMS, AF/SG,

AFMOA, and MAJCOM SGs, and provides consultant services to bases where NM personnel

(diet technicians) are assigned without a credentialed RD and where no NM capabilities or

personnel are assigned. The AF Career Field Manager (CFM) is the senior enlisted consultant to

the Associate Chief for Dietetics, AF SG Chief, Enlisted Medical Force (CMEF), MAJCOM

CMEF, and Diet Therapy MAJCOM Functional Managers (MFM), ensuring the development of

all enlisted personnel.

9.2. The Consultant Dietitian.

9.2.1. AF SG Consultant Dietitian/BSC Associate Chief for Dietetics. Consultant to AF SG

on all matters related to nutrition and dietetics. The Individual Mobilization Augmentee

(IMA) to the AF SG Consultant Dietitian serves as the Air Reserve Component (ARC)

advisor for Reserve dietitian career field issues.

9.2.2. MAJCOM Dietitians collaborate with DoD, AF/A1, AF SG Consultant Dietitian/BSC

Associate Chief for Dietetics, AFMOA Dietitian, HP Support Office stakeholders, subject

matter experts, and other agencies (e.g., Defense Commissary Agency, Army and Air Force

Exchange Service, national organizations, such as AND, and DoD/AF-level working groups,

such as the DoD Nutrition Committee, Community Action Information Board) as applicable

to research, develop, implement, market and evaluate evidence-based strategies and

interventions and initiatives to meet health promotion nutrition objectives.

9.2.3. MAJCOM Dietitians. MAJCOM Dietitians (senior active duty officers or civilians)

are appointed upon recommendation by the AF SG Consultant Dietitian. The MAJCOM

Dietitians, duties also include:

9.2.3.1. Serves as clinical supervisor to dietitians for credentialing purposes. The

MAJCOM Dietitian may approve a local credentialed provider to serve as clinical

supervisor.

9.2.3.2. Coordinates with AFMOA for training of HP dietitians and implementation of

HP nutrition strategies and interventions/initiatives as outlined in AFI 40-104.

9.2.3.3. Ensures credentialed RDs within the MAJCOM are trained to perform diet

technician diet authorizations/certifications as needed.

9.2.3.4. Ensures quarterly peer reviews of 15 patient notes or 100%, whichever is less,

are completed for all credentialed RDs and diet therapists assigned to the MAJCOM.

9.2.3.4.1. Submits Memorandum for Record (MFR) and hard copy peer review

reports (as applicable) quarterly to the member subject to peer review and to the

member’s Credentials Office as necessary.

9.2.3.4.2. Develops procedure to include MAJCOM-specific peer review schedule

and process for obtaining patient notes to review. (T-2). Requests those being peer

AFMAN44-144 20 JANUARY 2016 55

reviewed to provide a list of patients seen within the quarter (listing full patient’s

name and last four of SSN) is recommended which will allow the dietitian to select

which patient notes to review. Peer reviews on dietitians may be performed, if

required, by a local credentialed provider after coordination with the MAJCOM

Dietitian. A MFR or e-mail stating what peer reviews were accomplished and the

overall outcome will be provided to the MAJCOM Dietitian.

9.2.3.4.3. The electronic peer review system may be used as available and applicable.

9.2.3.5. Maintains quality communications with NM and facility personnel.

Communications should be frequent and well documented, as it is necessary to show

oversight and training by a RD to inspecting agencies. The consultant dietitian and each

NM section within their respective command must keep records of all communication

including e-mails, teleconferences, and video conferences.

9.2.3.6. Provides oversight of all NM activities/services at bases/facilities without a

credentialed dietitian assigned (only diet technician(s) assigned).

9.2.3.6.1. In coordination with AFMOA, reviews capability to provide rapid

telemedicine services to provide RD consultation if needed.

9.2.3.6.2. Ensures that NM services provided and compliance to regulations are

reviewed at least annually via Virtual Consultant Assistance (VCA) or more

frequently as requested by the facility.

9.2.3.6.3. Virtual Consultant Assistance (VCA). If it is not feasible to perform an in-

person Staff Assistance Visit (SAV), a VCA may be performed by webinar and/or

teleconference. Virtual consultation will be performed annually to continuously

evaluate NM services and compliance to regulations.

9.2.3.6.4. A specified member of the NM section undergoing the VCA is responsible

for ensuring all items identified below, that will be evaluated by the dietitian

providing the VCA, are sent electronically to the dietitian at least one month prior to

the VCA. (Evaluation of NM services by the MAJCOM Dietitian, or dietitian

designated by the MAJCOM Dietitian to perform the VCA, will include (but not

limited to) the following:

9.2.3.6.4.1. Any Medical Group Instruction involving NM service.

9.2.3.6.4.2. Internal Operating Instructions and Position Descriptions.

9.2.3.6.4.3. Training documentation (in-service plans and documentation, such as

lesson plans, competency assessment, attendee signatures, annual training

schedule), AF Training Record (AFTR) with emphasis on AF Form 628, Diet

Instruction/Assessment Authorization, and Competency/RSV Training

documentation.

9.2.3.6.4.4. Section organizational chart.

9.2.3.6.4.5. Last the JC/AAAHC/SAC/SAV reports.

9.2.3.6.4.6. Strategic planning documentation to include nutrition services

mission/vision/goals/objectives.

56 AFMAN44-144 20 JANUARY 2016

9.2.3.6.4.7. Process Improvement Program and nutrition program outcomes data.

9.2.3.6.4.8. Nutrition lesson plans and presentations used for group classes,

inpatient and outpatient forms, nutrition care overprints/screenings, etc.

9.2.3.6.4.9. Patient education materials and reference books.

9.2.3.6.4.10. Data quality/productivity reports.

9.2.3.6.4.11. Typical CHCS appointment schedule for RD and diet technicians.

9.2.3.6.4.12. Consultant dietitian communication log.

9.2.3.6.4.13. Compliance with TRICARE access to care standards.

9.2.3.6.4.14. Management tool monthly reports (as applicable) and management

plan.

9.2.3.6.4.15. Letter of agreement with base food services, patient menu, and

dining facility menu (if applicable).

9.2.3.6.4.16. Customer satisfaction surveys (inpatient/outpatient/dining facility).

9.2.3.6.4.17. Public Health Flight monthly sanitation inspection reports (one year

if applicable).

9.2.3.6.4.18. Equipment replacement plan.

9.2.3.6.4.19. Self-inspection documentation.

9.2.3.6.4.20. Food temperature charts (one year if applicable) and

refrigerator/freezer temperature charts (one year if applicable).

9.2.3.7. The VCA will be performed by an assigned credentialed dietitian at least

annually or as required. When a VCA includes the Health Promotion Program, the

assigned dietitian will coordinate the evaluation and final report with the Health

Promotion at AFMSA or AFMOA. (Each respective MAJCOM Consultant Dietitian is

responsible for creating a VCA/peer review schedule outlining which dietitian within

their command is responsible to conduct the VCA on which installations and when the

respective VCAs are due. After the VCA concludes, a copy of the final report must be

sent to the NM NCOIC, Squadron/Group Commander, the AF SG Consultant Dietitian,

and the nutrition staff at AFMSA and AFMOA. The final report is due within 1 month

after the VCA is conducted.

9.2.3.7.1. In-Person Staff Assistance Visits (SAV). Evaluation may be done through

face-to-face visits if virtual consultation is not sufficient to meet the facility needs at

the request of the WG Commander.

9.2.3.7.2. The same documents will be reviewed in the SAV as in the VCA and the

assigned credentialed dietitian performing the SAV must send a MFR to the facility

undergoing the SAV one month in advance. (T-3). An inbrief and outbrief with the

key leadership (to include the unit commander) of the facility undergoing the SAV is

encouraged. At the conclusion of the SAV, the final report is due within one month

and is sent to the same members identified in 8.2.3.10. Diet certifications may also

be performed during the in-person SAV or via telephone during a VCA.

AFMAN44-144 20 JANUARY 2016 57

9.2.3.8. Provides guidance, monitoring, and evaluation of nutrition services at MTFs

without any NM personnel assigned (no NM operation), and, when nutrition education in

HP programs is involved, collaborates with Health Promotion staff at AFMSA or

AFMOA.

9.3. Enlisted Consultant Roles.

9.3.1. Diet Therapy Career Field Manager Responsibilities are as follows: The Diet Therapy

AF CFM is appointed by the AF Surgeon General to ensure development, implementation,

and maintenance of the CFETP for the Diet Therapy career field. The CFM will

communicate directly with the Associate Chief for Dietetics, MFMs, ARC, and AETC

Training Pipeline Manager (TPM) to disseminate AF and career field policies and program

requirements. (

9.3.1.1. Use the Utilization and Training Workshop (U&TW)/Specialty Training

Requirements Team (STRT) meeting as forums and quality control tools to determine

and manage career field education and training (E&T) requirements.

9.3.1.2. Chair the portion of the STRT/U&TW for utilization, authorization, and general

career field mission issues, and partner with the AETC TPM throughout the

STRT/U&TW.

9.3.1.3. Ensure the direct involvement and participation of Subject Matter Experts

(SMEs) from the field.

9.3.1.4. Develop the CFETP as the core document for E&T requirements.

9.3.1.5. Establish the framework for managing career field E&T by specifying career

field progress.

9.3.1.6. Develop criteria to accelerate individual training when it is in the best interest of

the AF.

9.3.1.7. Oversee the Career Development Course (CDC) program for the Diet Therapy

career field. The AF CFM also reviews CDCs for accuracy and initiates actions to

develop new or revised CDCs to meet new requirements.

9.3.1.8. Ensure, when feasible, the direct involvement and participation of HQ Air

University A4L Extension Course Program personnel in U&TW proceedings impacting

development, revision, or deletion of CDCs or Specialized Courses used for career field

upgrade training.

9.3.1.9. Work closely with SG Chief, Enlisted Medical Force, MAJCOM CMEFs,

MFMs and Command Chief Master Sergeants (CCM) on training, development, manning

and personnel issues impacting NM personnel.

9.3.1.10. Support NM personnel with base initiatives and concerns while working with

MFM/MAJCOM RDs.

9.3.1.11. Advise HQ AFMPC/DPMRAD2 and the “Chiefs’ Group” on personnel

assignments.

58 AFMAN44-144 20 JANUARY 2016

9.3.2. Diet Therapy MAJCOM Functional Manager’s Responsibilities.

9.3.2.1. The primary duties and responsibilities of a MFM are outlined in AFI 36-2101,

Classifying Military Personnel (Officer and Enlisted), and AFI 36-2201. These duties

include, but are not limited to:

9.3.2.2. Assist in development and maintaining currency of CFETP. Establish review

procedures. Coordinate on new and proposed classification changes and publicizing

approved changes.

9.3.2.3. Serve as MAJCOM representative at AFSC 4D0X1 U&TW.

9.3.2.4. Assist technical training managers and course personnel with planning,

developing, implementing, and maintaining all 4D0X1 AFSC-specific training courses.

9.3.2.5. Assist the AF CFM, Air Force Occupational Measurement Squadron (AFOMS),

and CMEF in identifying subject matter experts for Specialty Knowledge Test rewrite

projects.

9.3.2.6. Assist AFOMS in developing and administering Job Surveys and interpreting

Occupational Survey Report data.

9.3.2.7. Coordinate and implement career field classification and structure changes.

9.3.2.8. Disseminate AF and career field policies and program requirements.

9.3.2.9. Maintain regular and consistent contact with MAJCOM MTF personnel to

include, but not limited to:

(1) Compilation and dissemination of information concerning process improvements.

(2) Compilation and dissemination of information concerning recent inspections.

(3) Address AFSC concerns/issues within the command and forward them to the CMEF who will

forward to the AF CFM.

9.3.2.10. Assignments: MFMs are only advisors and do not control assignments and

should not be considered as individuals who can manipulate the assignment system. The

medical enlisted assignment system is the responsibility of HQ AFMPC/DPMRAD2 and

the “Chiefs’ Group.” However, it is imperative that MFMs be knowledgeable of

authorizations and assignments within the MAJCOM to better serve as consultants to

MAJCOM assignment managers regarding assignment actions. As such, they may:

(1) Identify candidates for PCS/PCA/TDY assignments.

(2) Advertise position vacancies for urgent (short notice separations/discharges, etc.) and routine fill

requirements.

(3) Recommend/initiate resolution of staffing imbalances between MTFs (command leveling).

(4) Assist assignment staffers by fielding inquiries pertaining to career progression and classification.

(5) Be knowledgeable of authorizations and assignments within the MAJCOM and identify special

needs.

9.3.2.11. Notify CMEF and AF CFM of areas of concern within assigned MAJCOM

such as early discharge/dismissal, chronic shortages, inspections resulting in marginal or

unsatisfactory scores, two-time CDC failures, etc.

AFMAN44-144 20 JANUARY 2016 59

9.3.2.12. Participate in monthly teleconferences, relaying manning, training and any

personnel issues which need to be communicated to a higher level or just shared for

informational purposes.

9.3.2.13. Participate in annual strategic planning initiatives and provide input to shape

the future direction of the career field. (

9.3.2.14. Work closely with the MAJCOM Dietitian to ensure all enlisted member’s

concerns are addressed.

9.3.2.15. Fulfill any other duties as required by the CMEF and AF CFM.

9.4. NM Dietitian or Diet Therapy Personnel.

9.4.1. The dietitian or diet therapy personnel serve as a nutrition advisor to local media, HP,

base and community organizations. (T-3). Only a dietitian shall serve as nutrition advisor to

the MTF Commander. NM advisor responsibilities include:

9.4.1.1. Medical Staff. Serves as a nutrition resource for the medical and support staff

and the MTF Commander regarding diet prescriptions, nutritional supplements, medical

foods, nutrition assessment, MNT, current nutrition concepts and research. (T-2).

9.4.1.2. Health Promotion Program. Coordinate with Headquarters staff on guidance

related to HP nutrition program activities as nutrition advisor for other components of the

HP program involving nutrition education and disease prevention. (T-2). Provide

nutrition advice to Force Support Squadron to create an environment conducive to

healthy eating. Also serves as a community nutrition resource for base agencies such as

the Child and Youth Programs. (T-2). These responsibilities are performed by the health

promotion nutrition specialist if the capability exists. (T-2).

9.4.1.3. Professional Assistance. Provides interim professional assistance to the NM

operations by telephone or electronically. (T-2). NM staff in MTFs without dietitians

must record interim communications with the consultant in a log book or maintain copies

of electronic communications, noting subjects discussed and information communicated

by the consultant. (T-2).

MARK A. EDIGER

Lieutenant General, USAF, MC, CFS

Surgeon General

60 AFMAN44-144 20 JANUARY 2016

Attachment 1

GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION

References

DOD 1338.10-M, Manual for the Department of Defense Food Service Program, March 1990

DOD 6010.13-M, Medical Expense and Performance Reporting System for Fixed Military

Medical and Dental Treatment Facilities Manual, 7 April 2008

DOD Financial Management Regulation 7000.14-R, Vol 5, Disbursing Policy and Procedures,

Chapter 3, Keeping and Safeguarding Public Funds, January 2010

DODI 6025.24, Provision of Food and Beverages to Certain Members and Dependents Not

Receiving Inpatient Care in Medical Treatment Facilities, 07 March 2014

DODI 6130.50, DoD Nutrition Committee, 18 February 18 2011

AFPD 40-1, Health Promotion, 17 December 2009

AFPD 44-1, Medical Operations, 1 September 1999

AFI 33-332, Air Force Privacy and Civil Liberties Program, 12 January 2015

AFI 36-807, Weekly and Daily Scheduling of Work and Holiday Observances, 21 June 1999

AFI 36-1001, Managing the Civilian Performance Program, 1 July 1999

AFI 36-2101, Classifying Military Personnel (Officer and Enlisted), 25 June 2013

AFI 36-2201, Air Force Training Program, 15 September 2010

AFI 36-2406, Officer and Enlisted Evaluation Systems, 2 January 2013

AFI 36-2618, The Enlisted Force Structure, 27 February 2009

AFI 36-2905, Fitness Program, 21 October 2013

AFI 38-101, Air Force Organization, 16 March 2011

AFI 40-101, Health Promotion, 17 October 2014

AFI 40-104, Health Promotion Nutrition, 17 October 2014

AFI 41-102, Air Force Medical Expense and Performance Reporting System (MEPRS) For

Fixed Military Medical and Dental Treatment Facilities, 9 May 2014

AFI 41-106, Medical Readiness Program Management, 22 April 2014

AFI 41-301, Worldwide Aeromedical Evacuation System, 1 August 1996

AFI 41-307, Aeromedical Evacuation Patient Considerations and Standards of Care, 20 August

2003

AFI 44-102, Medical Care Management, 17 March 2015

AFI 44-108, Infection Prevention and Control Program, 11 December 2014

AFI 44-119, Medical Quality Operations, 16 August 2011

AFI 44-141, Nutrition Standards and Education, 15 June 2001

AFMAN44-144 20 JANUARY 2016 61

AFI 48-116, Food Safety Program, 19 August 2014

AFI 48-117, Public Facility Sanitation, 26 June 2014

AFI 64-117, Air Force Government-Wide Purchase Card (GPC) Program, 20 September 2011

AFI 90-201, The Air Force Inspection System, 21 April 2015

AFJMAN 34-406V2, Index of Recipes, Armed Forces Recipe Service, 1 September 1992

AFMAN 41-120, Medical Resource Management Operations, 6 November 2014

AFMAN 48-147_IP, Tri-Service Food Code, 30 April 2014

AF NM Accounting Spreadsheet (https://kx.afms.mil/nutritionalmedicine)

AFMS Flight Path (https://kx.afms.mil/bsc)

AND Evidence Analysis Library (www.andeal.org)

AND Nutrition Care Manual (www.nutritioncaremanual.org)

AND Nutrition Care Process (www.eatright.org/HealthProfessionals/content.aspx?id=7077)

AND Patient Education Materials (www.eatright.org)

AND Pediatric Nutrition Care Manual (www.nutritioncaremanual.org)

AND Sports Nutrition Care Manual (www.nutritioncaremanual.org)

AND Pocket Guide to Nutrition Assessment (www.eatright.org)

ASPEN Nutrition Support Core Curriculum (www.nutritioncare.org)

Career Field Education and Training Plan (CFETP) 4D0X1, Diet Therapy

(https://kx.afms.mil/nutritionalmedicine)

CNM Nutrition Screening Practices in Health Care Organizations (www.cnmdpg.org)

Computrition On-Line User Manual (https://kx.afms.mil/nutritionalmedicine)

DSCP Prime Vendor Guide Book (www.dscp.dla.mil/subs/pv/pvguide.pdf)

Health Services Inspection Standards (https://kx.afms.mil/afia)

International Dietetics & Nutrition Terminology Reference Manual (www.eatright.org)

Joint Commission for the Accreditation of Healthcare Organizations Standards

(www.jointcommission.org)

Memorandum from the Assistant Secretary of Defense for Health Affairs, Diplomate Pay for

Psychologists and Board Certification Pay for Non-Physician Health Care Providers, 9 March 09

(https://kx.afms.mil/bsc)

Memorandum from the Assistant Secretary of Defense for Health Affairs, National Defense

Authorization Act for Fiscal Year 2009 Permanent Prohibition Against Requiring Certain Injured

Members to Pay for Meals Provided by Military Treatment Facilities

(https://kx.afms.mil/nutritionalmedicine)

NM KX Website (https://kx.afms.mil/nutritionalmedicine)

USDA My Plate (http://myplate.gov)

62 AFMAN44-144 20 JANUARY 2016

USDA Dietary Guidelines for Americans (www.health.gov/dietaryguidelines)

Prescribed Forms

AF Form 541, Nutritional Medicine Service Subsistence Cost Report

AF Form 542, Subsistence Stock Record

AF Form 543, Food Issue Record

AF Form 544, Nutritional Medicine Daily Facility Summary Report

AF Form 546, Food Cost Record

AF Form 628, Diet Instruction/Assessment Authorization

AF Form 1094, Diet Order

AF Form 1737, Selective Menu (White) (3-way perforation)

AF Form 1738, Therapeutic Menu (Yellow) (3-way perforation)

AF Form 1739, Selective Menu (White) (6-way perforation)

AF Form 1740, Therapeutic Menu (Yellow) (6-way perforation)

AF Form 1741, Diet Record

AF Form 2464, CTIM Telephone Diet Order

AF Form 2478, Sodium Restricted (Pink) (3-way perforation)

AF Form 2479, Diabetic (Green) (3-way perforation)

AF Form 2480, Diabetic (Green) (6-way perforation)

AF Form 2481, Liquid (Yellow) (3-way perforation)

AF Form 2482, Liquid (Yellow) (6-way perforation)

AF Form 2485, Sodium Restricted (Pink) (6-way perforation)

AF Form 2487, Step 1 Moderate; Step 2 Strict Cholesterol and Fat Diet (Blue) (3-way

perforation)

AF Form 2488, Step 1 Moderate; Step 2 Strict Cholesterol and Fat Diet (Blue) (6-way

perforation)

AF Form 2497, Fat Restricted (Blue) (3-way perforation)

AF Form 2498, Fat Restricted (Blue) (6-way perforation)

AF Form 2499, Calorie Restricted (Green) (3-way perforation)

AF Form 2500, Calorie Restricted (Green) (6-way perforation)

AF Form 2503, Nutritional Medicine Service Patient Evaluation

AF Form 2504, Nutritional Medicine Service Patron Evaluation

AF Form 2508, Patient Calorie Count Sheet

AF Form 2567, Diet Order Change

AFMAN44-144 20 JANUARY 2016 63

AF Form 2568, Nourishment Request (Bulk)

AF Form 2570, Nutritional Medicine Service Cash and Forms Receipt

AF Form 2582, Food Temperature Chart

AF Form 2572, Nutritional Assessment of Dietary Intake

AF Form 2573, Diet Census

AF Form 2577, Medical Food Service – Daily Work Assignment

AF Form 2579, Nourishment

AF Form 3574, Pureed/Blenderized Liquid (Yellow) (3-way perforation)

AF Form 3575, Pureed/Blenderized Liquid (Yellow) (6-way perforation)

AF IMT 79, Headcount Record

Adopted Forms

DD Form 714, Meal Card

DD Form 792, Twenty-Four Hour Patient Intake and Output Worksheet

AF Form 28, War Reserve Materiel (WRM) Ration Report

AF Form 40a, Record of Individual Inactive Duty Training

AF Form 55, Employee Safety and Health Record

AF Form 847, Recommendation for Change of Publication

AF Form 1254, Register of Cash Collection Sheets

AF Form 1305, Receipt for Transfer of Cash and Vouchers

AF Form 2581, Daily Absenteeism Record

AF Form 3066, Doctor’s Order

AF Form 3067, Intravenous Record

AF Form 3516, Food Service Inventory Transfer Receipt

AF Form 3930, Clinical Privileges – Dietetics Providers

OPM Form 71, Application for Leave

SF 509, Medical Record Progress Note

SF 513, Medical Record – Consultation Sheet

SF 600, Chronological Record of Medical Care

Abbreviations and Acronyms

AAAHC—Accreditation Association for Ambulatory Health Care

AND—Academy of Nutrition and Dietetics

ADIME—Assessment, Diagnosis, Intervention, Monitoring, Evaluation

64 AFMAN44-144 20 JANUARY 2016

AETC—Air Education and Training Command

AF—Air Force

AFI—Air Force Instruction

AFMOA—Air Force Medical Operations Agency

AFOMS—Air Force Occupational Measurement Squadron

AFOSH—Air Force Occupational Safety and Health

AFPD—Air Force Policy Directive

AFMS—Air Force Medical Service

AFRIMS—Air Force Records Information Management Systems

AFSC—Air Force Specialty Code

AFSVA—Air Force Services Activity

AFTR—Air Force Training Records

AIDS—Acquired Immune Deficiency Syndrome

ALACS—A la Carte System

AMA—American Medical Association

APV—Ambulatory Procedure Visit

ARC—Air Reserve Component

ASF—Aeromedical Staging Facility

ASPEN—Association of Enteral and Parenteral Nutrition

ASTS—Aeromedical Staging Squadron

BDFA—Basic Daily Food Allowance

BLS—Basic Life Support

BSC—Biomedical Sciences Corps

CAC—Common Access Card

CBRN—Chemical, Biological, Radiological, and Nuclear

CCM—Command Chief Master Sergeant

CDC—Career Development Course

CDE—Certified Diabetes Educator

CDM—Certified Dietary Manager

CFETP—Career Field Education and Training Plan

CFM—Career Field Manager

CEU—Continuing Education Unit

AFMAN44-144 20 JANUARY 2016 65

CFM—Career Field Manager

CHCS—Composite Health Care System

CHES—Certified Health Education Specialist

CMEF—Chief, Enlisted Medical Force

CNM—Certified Nurse Midwife

CNSC—Certified Nutrition Support Clinician

CONUS—Continental United States

COPD—Chronic Obstructive Pulmonary Disease

CPG—Clinical Practice Group

CSG—Certified Specialist in Gerontological Nutrition

CSO—Certified Specialist in Oncology Nutrition

CSP—Certified Specialist in Pediatric Nutrition

CSR—–Certified Specialist in Renal Nutrition

CSSD—Certified Specialist in Sports Dietetics

DCO—Defense Connect Online

DeCA—Defense Commissary Agency

DFAC—Dining Facility

DFAS—CO—Defense Finance & Accounting Service – Columbus

DHP—Defense health Program

DMA—Dietary Managers Association

DMRSHi—Defense Medical Human Resources System-internet

DoD—Department of Defense

DODAAC—Department of Defense Activity Address Code

DSCP—Defense Supply Center Philadelphia

DVA—Department of Veterans Affairs

ECR—Electronic Cash Registers

ED—Emergency Department

EHR—Electronic Health Record

EMEDS—Expeditionary Medical Support

ESM—Essential Station Messing

FAC—Functional Account Code

FAND—Fellow of the Academy of Nutrition and Dietetics

66 AFMAN44-144 20 JANUARY 2016

FCC—Functional Cost Codes

FDA—Food and Drug Administration

FOM—Food Operations Management

FOUO—For Official Use Only

GPC—Government Purchase Card

GPN—Graduate Program in Nutrition

HACCP—Hazard Analysis Critical Control Points

HAZMAT—Hazardous Material

HCP—Health Care Provider

HIPAA—Health Insurance Portability and Accountability Act

HIV—Human Immunodeficiency Virus

HPP—Health Promotion Program

IDNT—International Dietetics and Nutrition Terminology

IDS—Integrated Delivery System

IT—Information Technology

JC—Joint Commission

KX—Knowledge Exchange

LIFO—Last In First Out

MAJCOM—Major Command

MAOI—Monoamine Oxidase Inhibitors

MCRP—Medical Contingency Response Plan

MedFACTS—Medical Facility Assessment and Compliance Tracking System

MEPRS—Medical Expense Performance Reporting System

MFM—MAJCOM Functional Manager

MFR—Memorandum for Record

MILSTRIP—Military Standard Requisitioning and Issue Procedure

MNT—Medical Nutrition Therapy

MOA—Memorandum of Agreement

MPA—Military Personnel Appropriation

MRDSS—Medical Readiness Decision Support System

MRE—Meals Ready to Eat

MTF—Medical Treatment Facility

AFMAN44-144 20 JANUARY 2016 67

NCM—Nutrition Care Manual

NCP—Nutrition Care Process

NCOIC—Noncommissioned Officer in Charge

NDC—Nutritional Diagnostic Category

NIH—National Institutes of Health

NM—Nutritional Medicine

NMC—Nutritional Medicine Clinic

NMIS—-Nutrition Management Information System

NMA—Non-Medical Attendant

NPBCP—Non-Physician Health Care Provider Board Certified Pay

NPI—National Provider Identifier

NPO—Nothing Per Oral

NSN—National Stock Number

OPM—Office of Personnel Management

OIC—Officer in Charge

OMG—Objective Medical Group

OPAC—On-Line Payment & Collection

OSHA—Occupational Safety and Health Administration

PA—Privacy Act

PA—Physician Assistant

PAS—Privacy Act Statement

PDO—Publications Distribution Office

PES—Problem Etiology Signs/Symptoms

PI—Performance Improvement

PNCM—Pediatric Nutrition Care Manual

PPN—Peripheral Parenteral Nutrition

PTS—Patient Tray Service

QTP—Qualification Training Package

RCEP—Registered Clinical Exercise Physiologist

RD—Registered Dietitian

RDS—Records Disposition Schedule

REE—Resting Energy Expenditure

68 AFMAN44-144 20 JANUARY 2016

RES—Registered Exercise Specialist

RMO—Resource Management Office

RON—Remain over night

RSV—Readiness Skills Verification

RTH—Ready to Hang

SAC—–Self-Assessment Checklist

SAV—Staff Assistance Visit

SCAMS—Subsistence Credit Allowance Management System

SDS—Same Day Surgery

SF—Standard Form

SIMS—Services Information Management System

SME—Subject Matter Expert

SNCM—Sports Nutrition Care Manual

SOFA—Status of Forces Agreement

STORES—Subsistence Total Receipt Electronic System

STRT—Specialty Training Requirements Team

TF—Tube Feeding

TIM—Therapeutic Inflight Meal

TPM—Training Pipeline Manager

TPN—Total Parenteral Nutrition

UCA—Uniform Cost Accounting

UGR—Unitized Group Ration

UMD—Unit Manning Document

UMPR—Unit Personnel Management Roster

URL—Uniform Resource Locator

USAF—US Air Force

USDA—United States Department of Agriculture

U&TW—Utilization and Training Workshop

VA—Veterans Administration

VCA—Virtual Consultant Visit

WW—Wounded Warrior

AFMAN44-144 20 JANUARY 2016 69

Terms

A La Carte System (ALACS)—A system in which the dining facility cash patrons are charged

for each menu item selected. Each food item is priced and sold by the individual portion.

Essential Station Messing (ESM) patrons “pay” by meal card number or social security number

instead of cash, as under conventional food service policies.

Academy of Nutrition and Dietetics (AND)—The parent professional organization that

establishes standards of practice for the training and performance of RDs.

Ambulatory Procedure Visit (APV)—Formerly known as same day surgery, refers to the

immediate (day of procedure), pre-procedure and immediate post-procedure care in an

ambulatory setting. Care is in the facility for less than 24 hours.

Burlodge—The Burlodge company supplies specialized patient meal assembly and delivery

systems particularly suited to conventional hot-line/cook-serve and cook-chill applications.

Computrition—Computrition’s Hospitality Suite Commercial-off-the-shelf (COTS) software

solution replaces the legacy Government off-the-shelf (GOTS) system originally deployed in

1994 and is comprised of two key products: Foodservice Operations Management (FOM) and

Nutrition Care Management (NCM). The FOM provides automated daily functions such as

menu planning, purchasing, inventory, production, recipe management, and forecasting that the

former NMIS GOTS application once handled, as well as new features such as food and labor

costing, nutrient labeling, and HACCP compliance procedures. The NCM includes the ability to

track patient demographics, acuity levels, diet orders, weight history, as well as any likes,

dislikes, or allergies, menu and tray ticket production, comprehensive nutrient analysis, recipe

and menu management, the generation of automated HACCP guidelines. The software

application is designed to interface with the Electronic Health Record (Essentris) and the

Subsistence Total Order and Receipt Electronic System (STORES).

Food Cost Index— A representative list of specified quantities of food items (components)

prescribed by DOD and used to compute the monetary value of the operational basic daily food

allowance (Operational BDFA).

Food Service Operating Expenses—A charge established to comply with the congressional

requirement to recover a part of personnel and operational-maintenance costs. Food service

operating expense is generally charged to officers, civilians, and enlisted personnel not receiving

ESM who eat in appropriated fund facilities (formerly known as surcharge).

Government Purchase Card (GPC)—The Government Purchase Card is the official

government-wide purchase credit card.

Hazard Analysis Critical Control Point (HACCP)—A systematic approach to the

identification, evaluation, and control of food safety hazards.

Joint Commission (JC)—The accreditation body for medical treatment facilities.

Meal—A portion of food taken at one time.

Meal Day—A value in which the number of meals is weighted by a predetermined percentage to

balance the cost and attendance variances between the meals. The number of meal days for a

given day is figured by multiplying the number of breakfast, lunch, and dinner meals served by

70 AFMAN44-144 20 JANUARY 2016

the factored percentages of 20, 40, and 40 percent, respectively, and totaling the results (formerly

called ration).

Meal Periods—Breakfast: The meal served during the morning hours and considered the first

meal of the day. Lunch: The meal served at midday and considered the second meal of the day.

Dinner: The meal served during the evening hours and considered the third meal of the day.

Night Meal: The meal served between the dinner and breakfast meals. Dinner or breakfast type

meals may be served. The meal credit and reimbursement rates are based on the menu actually

served. The night meal is for persons on night duty.

Medical Foods—Enteral feedings and dietary supplements which enhance or replace regular

foods for patients with special feeding requirements.

"Nil per os" or "Nothing By Mouth"(NPO)—The patient will receive no food or beverages

from Nutritional Medicine Flight when this diet order is written.

Nutrition Management Information System (NMIS)—NMIS is a joint service multifunctional

management information system designed to replace the TRIFOOD system. NMIS provides the

following functions: data maintenance, production planning, menu cycle planning, NM

accounting, forecasting, inventory management, management reporting, a la carte/conventional

meal service pricing, diet office functions and nutrition outcomes management functionality.

Nutritional Diagnostic Category (NDC)—A fundamental class of nutritional problems, used to

categorize a patient’s nutritional condition.

Prime Vendor—Customized contracts developed with commercial distributors that are designed

to furnish a full range of subsistence goods and delivery services with emphasis on quality,

availability and minimum delivery lead time.

Ration—Refers to a portion or type of food.

Subsistence—Food products as packaged, bought, sold, and issued.

Therapeutic In—flight Meals (TIMs)—Therapeutic diet foods provided by the medical

treatment facility to patients receiving a prescribed therapeutic diet who are embarking on

aeromedical evacuation flights. There is no longer CTIMS, Cooked Therapeutic In-Flight Meals

Unitized Group Ration—A pre-packaged, heat and serve ration designed to feed a complete

meal for 50 persons. This combination ration replaces the B and T rations and makes maximum

use of commercial items.

Virtual Consultant Assistance (VCA)—A virtual means to conduct what was formally known

as a SAV to ensure NM operations are inspection ready specifically in locations without a RD.

Weighted Diet Census—Total of diet census after applying weighted percentages to certain

therapeutic patients based on difficulty of procedures.

Weighted Meal Days—The total of the percentage of a whole meal day multiplied by a

particular meal count(s).

AFMAN44-144 20 JANUARY 2016 71

Attachment 2

4D0X1 DIET TECH DIET COUNSELING AUTHORIZATION GUIDE

Table A2.1. 4D0X1 Diet Tech Diet Counseling Authorization Guide.

GENERAL

CATEGORY

DIET TECH AUTHORIZATION

ALLOWED

DIET TECH AUTHORIZATION

NOT ALLOWED; MUST BE

PERFORMED BY REGISTERED

DIETITIAN ONLY

Adverse Reactions to

Food

 Food

Allergies/Hypersensitivities in

Adults

 Lactose Intolerance

 Food Allergies/Hypersensitivities in

Pediatric Patients Under 18 Years

of Age

 Multiple Food Allergies

Cancer

 Cancer Prevention

 Cancer

Cardiovascular

Disease

 Cardiovascular Disease (Diet

for dyslipidemia)

 Hypertension (DASH Diet)

 Metabolic Syndrome

 Congestive Heart Failure-

COPD

 COPD

Cystic Fibrosis

 Cystic Fibrosis

Diabetes/Endocrine

 Adult Type 1 and 2 with no

complications (renal,

hypoglycemia, etc.)

 Gestational Diabetes not on

insulin

 Reactive Hypoglycemia

 Adult Type 1 and 2 WITH

complications (renal,

hypoglycemia, etc.)

 Gestational Diabetes on Insulin

 Diabetes (Under 18 years of Age)

 Disaccharidase Deficiencies

Diet-Drug Nutrient

Interactions

 Coumadin

 MAOIs

 All Others

Eating

Disorders/Feeding

Problems

 High Calorie/Protein for weight

maintenance (malnutrition not

present)

 All Eating Disorders (Bulimia,

Anorexia Nervosa, Compulsive

Overeating, etc.)

 Failure To Thrive (Pediatric and

72 AFMAN44-144 20 JANUARY 2016

GENERAL

CATEGORY

DIET TECH AUTHORIZATION

ALLOWED

DIET TECH AUTHORIZATION

NOT ALLOWED; MUST BE

PERFORMED BY REGISTERED

DIETITIAN ONLY

Adult)

 Diet for Dysphagia

Fitness Nutrition

 Fitness Improvement Program

Gastrointestinal

Disease

 Peptic Ulcer Disease

 Gastroesophagheal Reflux

Disease

 Celiac Disease

 Irritable Bowel Syndrome

 Colitis

 Crohn’s Disease

 Malabsorption, intestinal

 Postop Surg Syndromes/By-Pass

 Gluten-Restricted

 Gliadin-Free Diet

 Postgastrectomy

HIV/AIDS

 HIV/AIDS

Lifecycle Nutrition

 Breast Feeding/Lactation

 Vegetarian Diets

 Healthy Prenatal Nutrition

(including calorie controlled)

 Vegan

 Vegetarian Diets During Pregnancy

 Hyperemesis Gravidarium

Liver Disease

 Hepatitis

 Liver Disease

 Nephrotic Syndrome

Malnutrition

 Marasmus, Nutritional

 Kwashiorkor

 Protein – Calorie Malnutrition

AFMAN44-144 20 JANUARY 2016 73

GENERAL

CATEGORY

DIET TECH AUTHORIZATION

ALLOWED

DIET TECH AUTHORIZATION

NOT ALLOWED; MUST BE

PERFORMED BY REGISTERED

DIETITIAN ONLY

Miscellaneous

Therapeutic Diets

 Fat-Restricted

 Fiber-Restricted

 High-Fiber

 High-Calorie, High-Protein

 Purine-Restricted Diet

 Tyramine-Restricted Diet

 All Others

Modified Consistency

 Blenderized

 Mechanically Altered Diet

Modified Mineral

 Calcium

 Potassium

 Iron

 Sodium Restricted

 Overall Dietary Inadequacies

Warranting Use of Multi-

vitamin

 All Others

 Ascites (Sodium Restriction Under

2 gm)

Nutrition Screening

 Nutrition Screening

 Nutrition Assessment of Patients at

High Nutritional Risk. Nutrition

assessment of other patients per

local guidance and diet technician

authorization.

Nutrition Support

 Tube Feeding

 Total Parenteral Nutrition

Renal Disease

 Urolithiasis

 Chronic Renal Failure

 Acute Renal Failure

 Dialysis

Substance Abuse

 Healthy Nutrition for substance

74 AFMAN44-144 20 JANUARY 2016

GENERAL

CATEGORY

DIET TECH AUTHORIZATION

ALLOWED

DIET TECH AUTHORIZATION

NOT ALLOWED; MUST BE

PERFORMED BY REGISTERED

DIETITIAN ONLY

abuse, chemical dependency

Supplements

 General information and

awareness about supplements

 Specific/prescriptive guidance on

supplements

Transplant Diets

 All

Weight Management

 Calorie Controlled Diet for

Weight Management

 Pediatric Healthy Weight

Management Principles (no

assigned calorie level) with

parent/guardian present; <5 yrs

old requires contact with

MAJCOM Dietitian.

 Very Low Calorie Diets <1200

Calories for Female, <1500 for

Males)

 Pediatric Weight Management

(Assigned Calorie Level) (<18 yrs

old)

AFMAN44-144 20 JANUARY 2016 75

Attachment 3

PERSONS AUTHORIZED TO EAT IN MILITARY TREATMENT FACILITY DINING

FACILITIES

A3.1. Authority. DOD 1338.10-M.

A3.2. Category Definition. Charges for persons authorized to eat in a USAF MTF dining

facility vary, depending on the status of each person. The five major categories of personnel are:

officers, enlisted personnel, military dependents, federal civilian employees, and others.

A3.3. General Entitlements. See Table.

A3.4. Special Considerations:

A3.4.1. Outpatients and visitors may eat in MTF dining facility when authorized to do so by

the MTF commander, but must pay either the discount or full meal rate, depending on their

status.

A3.4.2. Inpatients traveling in the aeromedical evacuation system are not charged for their

meals.

A3.4.3. Outpatients traveling in the aeromedical evacuation system pay the full rate for their

meals in the dining facility.

A3.4.4. Nonmedical attendants traveling in the aeromedical evacuation system pay the full

meal rate, regardless of category. (Exception: Dependents of E-4 and below pay the discount

rate).

A3.4.5. Military members of foreign governments pay the same rates as their US

counterparts.

A3.4.6. National Guard and Air National Guard, the ROTC (all services), and the Army, Air

Force, Navy, Marine, and Coast Guard Reserves, on active duty or inactive duty for training,

pay the same rates as their active duty counterparts. They can pay for meals with cash or by

cross service billing.

A3.4.7. Wounded Warriors (WW). With proper identification, WWs receiving inpatient or

outpatient care at the MTF are not charged for meals.

A3.4.8. Outpatients undergoing medical procedures involving extended (4 hours or as per

recommended dietary requirements) periods, a who are unable to purchase food or beverages

by virtue of receiving such care, must pay either the discount or full meal rate, depending on

their status .

A3.4.9. A family member who provides care to an infant receiving inpatient medical care,

who is unable to purchase food or beverages by virtue of providing such care to the infant,

must pay either the discount or full meal rate, depending on their status.

A3.4.10. The discount rate includes the cost of food only.

A3.4.11. The full rate includes the cost of food and a proportional charge for food service

operating expenses.

76 AFMAN44-144 20 JANUARY 2016

A3.4.12. Charges for meals are based on annual DOD rates. HQ USAF/SGMC provides the

rates to medical resource management officers by message in October.

A3.4.13. Food Service Operating Expenses waiver authority is at DOD level. Request for

waivers should be submitted to SAF/FMF, 1130 Air Force Pentagon, Washington, DC

20330-1130.

Table A3.1. Persons Authorized To Eat In MTF Dining Facilities.

These Customers

Pay This Amount

Discount Rate

Full Rate

Enlisted members drawing Basic Allowance for Subsistence (BAS).

Officers on duty in the MTF

Federal civilian employees on duty in the MTF.

Federal civilian employees on official duty as a result of an act of providence

or civil disturbance when no other comparable food service facilities are

available.

International Military Education Training (IMET) and Foreign Military Sales

(FMS) students not receiving the meal portion of per diem and the meal

operating charges are recovered through tuition charges.

IMET and FMS students when the operating charge is not included in tuition.

Officer candidate, cadet, midshipman, or ROTC/NROTC/AFROTC students in

training.

Members and chaperones of organized nonprofit youth groups extended the

privilege of visiting a base or who are operating on base and the installation

commander permits them to eat.

Students in DoD Dependents Schools overseas and alternative student meal

facilities are not available.

Family members of E-1 through E-4.

Active duty and nonactive duty aeromedical evacuation patients not receiving

per diem.

Active or nonactive duty non-medical attendant (NMA) to an aeromedical

evacuation patient, not receiving per diem.

Active duty aeromedical evacuation patients or NMAs on orders and receiving

per diem.

Anyone receiving the subsistence portion of per diem.

AFMAN44-144 20 JANUARY 2016 77

These Customers

Pay This Amount

Discount Rate

Full Rate

Full-time paid professional field and headquarters Red Cross staff workers,

full-time paid secretarial and clerical Red Cross workers on duty in Red Cross

offices, Red Cross volunteers, uniformed and non-uniformed, in CONUS and

overseas.

United Service Organization (USO) personnel authorized by the installation

commander.

Anyone who the installation commander allows when considered to be in the

best interest of the Air Force and no other adequate food service facilities are

available.

78 AFMAN44-144 20 JANUARY 2016

Attachment 4

TABLE A4.1 NUTRITIONAL MEDICINE SUBSISTENCE REPORT (EXCEL

SPREADSHEET).

MAJCOM

MTF

OBDFA

MBDFA

PBDFA

TOTAL

PURCHASES

COST OF

ISSUES

TOTAL

EARNINGS

TOTAL MEALS

TOTAL MEAL

DAYS

PATIENT MEAL

DAYS

OTHER MEAL

DAYS

OPERATIONAL

MEAL DAYS

TOTAL:

Instructions for completion:

MAJCOMs will submit a consolidated report, by MTF, on a monthly basis to AFMOA Uniform

Business Office. (T-1).

Definitions:

4a. OBDFA: Operational Basic Daily Food Allowance, provided by the base food services

officer,

without any modifications. Use to calculate operational rations.

4b. MBDFA: MTF Basic Daily Food Allowance. The OBDFA modified to include the cost

of 100% ground beef. Used to calculate SIK and CTIM meal earnings.

4c. PBDFA: Patient Basic Daily Food Allowance. MBDFA plus an additional 15% for patient

feedings. Used to calculate patient meal earnings.

4d. Total Meals: Total Meals served each month per AF Accounting Spreadsheet.

4e. Total Meal Days: Replaces the term "ration". Equivalent of 3 meals served in 24 hours. One

bed

day = one meal day.

4f. Patient Meal Day: Equals one bed day or the Ambulatory Procedure Visit (APV)

Equivalent, normally 40% per meal.

4g. Other Meal Day: All other meals served by the MTF dining facility.

4h. Operational Meal Day: Meals issued for exercises.

AFMAN44-144 20 JANUARY 2016 79

Attachment 5

SAMPLE MOA BETWEEN NM & BASE FOOD SERVICE

DEPARTMENT OF THE AIR FORCE

DATE

MEMORANDUM FOR (FORCE SUPPORT SQUADRON CC)

FROM: (REQUESTING CC)

SUBJECT: Patient Feeding Memorandum of Agreement (MOA)

1. The Patient Feeding MOA applies to the XXth Medical Support Squadron (MDSS),

Nutritional Medicine Flight (NMF), and the XXth Force Support Squadron (FSS), (name of

dining facility). The NCOIC of each activity will be the designated representatives. This MOA

addresses responsibilities and local procedures for routine hospital patient feeding under normal

conditions and patient feeding requirements during exercises, war, and disaster contingencies.

The MOA should be reviewed or renewed annually, upon transfer of NCOICs, and change in

agreement of responsibility or procedures.

2. Responsibilities and procedures for food support under normal conditions:

a. The (name of dining facility) will:

(1) Provide menus and notice of menu changes by calling the NMF at XXX-XXXX, or by

faxing the menus and changes to XXX-XXXX as soon as available. Ideally menu changes

should be provided to NMF at least 24 hours in advance.

(2) Provide hot meals along with the condiments to include: desserts, assorted fruits,

beverages etc.

(3) Assist NMF staff in packing food items in insulated food containers to be transported

to the medical facility.

(4) Contact NMF supervisor when procedures need revision or problems arise needing

resolution by either party.

80 AFMAN44-144 20 JANUARY 2016

(5) The (name of dining facility) will not prepare or cook any therapeutic diet menu

items, but will allow NMF staff the space and equipment to prepare therapeutic items in the

dining facility kitchen.

b. NMF will:

(1) Provide the (name of dining facility) a list of NMF personnel authorized to pick up

meals. The NMF NCOIC is responsible for preparing and updating the authorization letter(s)

which are signed by (NMF Chief) (Atch 2).

(2) Inform the dining facility supervisor or food production manager of the number of

meals needed no less than 1 hour prior to that specific meal hour. The number of meals

requested will correspond with those listed on the AF Form 79, Head Count Record (Atch 1).

AF Form 79 is used for accountability of meals and signed by the NMF technician.

(3) Assemble all meal trays for patients using available food from the dining facility’s

daily menu.

(4) Sanitize food preparation/tray assembly areas after each use and maintain designated

NMF storage areas in a neat and sanitary manner.

(5) Sanitize all insulated containers after each meal period. When insulated containers are

not used for more than a 24-hour time period they will be sanitized prior to use.

(6) Ensure all meals and food supplies obtained from the dining facility are secured in a

controlled area and used for patient feeding only.

(7) Whenever necessary, using MDG funds, purchase all supplements and special feeding

terms such as Ensure, Boost, Resource, and other items for patient snacks or specialty diet meals

from the base commissary for patients.

(8) Ensure dining facility is informed of all changes, additions or deletions to the patient

count within an appropriate amount of time so as to avoid an over-production of food or the

unnecessary waste of manpower assets.

3. Responsibilities and procedures for patient feeding during exercises.

a. NMF will: continue to pick up food from the base dining facility to feed patients.

b. The (Name of dining facility) will continue patient meal preparation as usual whenever

meals are requested.

4. The undersigned agrees to the terms of this MOA.

5. This letter supersedes all previous MOAs established between the two parties.

AFMAN44-144 20 JANUARY 2016 81

SIGNATURE BLOCK

Commander, XX Medical Support Squadron

2 Attachments:

1. AF Form 79, Head Count Record (controlled form)

2. List of Personnel Authorized to pick up meals

lst Ind, XX FSS/CC, Patient Feeding Memorandum of Agreement (MOA), (enter date)

MEMORANDUM FOR XX MDSS/CC

Approved/Disapproved

SIGNATURE BLOCK

Commander, XX Force Support Squadron

Annual Review Dates:

___________________________________

82 AFMAN44-144 20 JANUARY 2016

Attachment 6

NUTRITIONAL MEDICINE SERVICE OVERSIGHT CHECKLIST

(Reference: AFMAN 44-144, Nutritional Medicine)

Purchasing Subsistence:

 Do the appropriate Nutritional Medicine (NM) personnel have a thorough

knowledge/understanding of their Prime Vendor contract to include renewal timeframes?

 Are the duties of personnel purchasing subsistence separated from the duties of personnel

completing ration accounting so that no one individual is responsible for both originating

data and inputting/processing data?

 Has NM designated individuals authorized to accept or reject subsistence or supplies

delivered under prime vendor programs or other DSCP (Defense Supply Center Philadelphia)

contracts?

 Do designated personnel verify the hard copy purchase order with the vendor invoice from

the driver and ensure that products received match those ordered at the time of receipt so that

the vendor’s delivery ticket may be annotated with any discrepancies?

 Do invoices reflect only items and quantities accepted and signed for by the NM receiving

official?

 If /when discrepancies are detected upon receipt, is the vendor’s invoice annotated to indicate

actual quantities received by striking through the listed quantity and entering the received

quantity and reason for the differences?

 Each month, is SF 1080 verified?

 If available, is the NM subsistence GPC card appropriately (only for subsistence items to

support the preparation or serving of foods)?

Storing Subsistence:

 Are subsistence storage rooms, refrigerators, and freezers secure (locked) when not in use;

(exception: produce, and direct deliver/milk refrigerator)?

 Is entry for unauthorized personnel controlled, prohibited?

Inventory Controls:

AFMAN44-144 20 JANUARY 2016 83

 Is the storeroom manager maintaining the perpetual inventory system of subsistence stock

records, source documents for subsistence purchase and issues (entries include vendor

receipts and purchase invoices, GPC statements and receipts, or AF Forms 543, Food Issue

Record)?

 Is a physical inventory performed each month (except September) on one of the last three

normal duty days and representative as of the date of the inventory (with the exception of FY

close-out)? The FY close-out in September should be conducted on the last day of the FY

when possible (if not possible, then on the last duty day).

 Does the MTF Commander appoint a disinterested, trained person (officer or SNCO) to

perform a physical inventory of all food items? The inventory official delivers the completed

and signed inventory listing to the MSA Officer and NM Officer/NCOIC.

 If there are discrepancies/differences between the physical count and inventory records (that

cannot be resolved), is an Inventory Adjustment Report prepared?

 At the end of each quarter and the FY, is the dollar value of the closing inventory between

(not more than) 15% and 30% of the cumulative average monthly cost of food used for the

FY to date? MTFs using Prime Vendor should reduce inventory levels to 2-3 days’ supply.

Optimal inventory levels should be determined locally to ensure that adequate food is on

hand/available in case of disaster or emergency situations when deliveries may be disrupted.

Issuing and Costing Subsistence:

 Do storeroom personnel issue subsistence using Computrition (automated) or AF Form 543

(manual)? Direct delivery items may be issued on the day they are received. Perishable

fresh fruits and vegetables may be issued the day of purchase and receipt. High volume, low-

cost items may be issued as needed each day, or for a longer use period.

 Does the person receiving the food items from the storeroom count and verify food received

and sign the form in the received block? If more food items are issued than needed, are they

returned to inventory under the returned column?

 Does the MTF use the Last-In First-Out (LIFO) costing method for recording purchases and

costing items?

Cashier Operations:

 Is there separation of financial duties and responsibilities in authorizing, processing,

recording, and receiving cash transactions? Cashiering and accounting duties must be

separated to ensure adequate internal controls to prevent loss of funds.

 Does NM have: appropriate and authorized change fund (IAW DoD Financial Management

Regulation 7000.14-R, Vol 5); for a la carte operations, a cash control supervisor designated

84 AFMAN44-144 20 JANUARY 2016

in writing; and, an adequate funds storage safe to hold the change fund, cash sales, and

guarded forms (such as AF IMT 79)?

 Is AF Form 2570 used to issue the cash drawer and AF IMT 79 to the cashier? Is the same

AF Form 2570 used by the cashier to return the cash drawer, cash collected, and AF IMT 79

to the cash control officer after the meal? Are any discrepancies noted on the AF IMT 79?

 Does the cash control supervisor indicate funds and guarded forms (AF IMT 79) for turn in

to MSA Office using AF Form 1305 for cash collected and AF Form 1254 for guarded forms

used to document the transfer of responsibility from NM to the MSA Office?

 Does the cash control supervisor indicate funds and guarded forms (AF IMT 79) for turn in

to MSA Office using AF Form 1305 for case collected and AF Form 1254 for guarded forms

used to document the transfer of responsibility from NM to MSA?

 Is all cash collected and AF IMT 79 forms used turned in to the MSA office daily, excluding

weekends? If the storage limit on the safe/funds storage container is inadequate to support

the amount of cash collected over a 2 or 3 day weekend, NM should make arrangements with

the MSA Office to turn in cash during the weekend or request an increase in the amount of

funds that can be stored. In any case, cash deposit paperwork must be done on a daily basis,

even if the funds must be held over the weekend.

 Are cash registers correctly programmed to calculate both the charge cash patrons the DoD-

directed surcharge and correctly total the surcharges from each meal period?

 Is the MTF MSA Office correctly dividing the surcharge between the AF Military Personnel

Appropriation and the Defense Health Program O&M appropriation? MSA Office is

supposed to proportionately divide the surcharge accordingly with the start of each FY.

 If the NM DFAC does not have cash registers (SCAMS operations), do all diners, except

ambulatory and transient patients, sign for meals using the appropriate number of AF IMT

79s for each meal? Does the cashier verify the diner’s identification?

 Are completed AF IMT 79 forms and collected cash delivered to the MSA Office at least

once each normal duty day and the MSA Office verifies the cash receipts against the total

amount of cash received as annotated on AF IMT 79s?

Eligibility and Identification of Diners:

 Is diner eligibility and identification correctly verified?

 Are diners appropriately processed based on their status?

Recipe Pricing:

AFMAN44-144 20 JANUARY 2016 85

1. For a la carte operations, is each recipe item priced and sold on an individual item basis?

Computrition menu pricing reports such as the Computrition Recipe Price Report should

be used/available; if not, each recipe cost must be manually calculated. Menu item

pricing must include DoD surcharges.

NM Ration Accounting:

 Are NM accounting parameters accurate and up to date, whether calculated/using the AF

Accounting Spreadsheet (Excel) or manually?

 Is the MTF Basic Daily Food Allowance (BDFA) accurately calculated, on a monthly basis,

using the most current monthly Food Cost Index (FCI)?

 Is the Patient BDFA correctly calculated (BDFA plus 15% supplemental allowance)? Is the

Patient BFDA only used to calculate patient meal day earnings?

 If applicable, were NM activities using SCAMS and serving less than 100 average daily meal

days for both patient and DFAC patron rations applying the authorized additional

supplemental allowance of 15% of the MTF BDFA (this is called the small volume feeding

allowance/percentage)? This eligibility is determined at the end of each month and is applied

to ESM and SCAMS DFAC patrons only. It is not authorized for a la carte cash sales. If

allowed, the 15% supplemental allowance is used to figure the next month’s MTF BDFA.

 If applicable, was the Therapeutic In-flight Meals (TIMs) allowance appropriately

applied/used? A special monetary allowance equal to 80% of the MTF BDFA is authorized

for each TIM furnished by NM for aeromedical evacuation patients to consume in-flight.

 Were holiday and special meal percentages/allowances of an additional 25% (for federal

holidays, the AF birthday, and Easter) and 15% (for airman appreciation meals) appropriately

applied to ESM DFAC patrons at all facilities and cash patrons at SCAMS facilities (a la

carte facilities do not receive an additional 25% for cash customers of patients during these

meals)? To claim the additional percentage, holiday meals must be served on the actual day

designated as the holiday. Christmas and Thanksgiving holiday meals must be served at the

lunch meal. There must be a special menu planned and served to qualify for the allowance.

 Are occupied bed days accurately calculated? Occupied bed day refers to the number of

inpatients subsisting in the MTF and equals beds occupied minus bassinets from the

Admission and Disposition Recapitulation Report.

 Are meal days accurately calculated? A meal day is a value in which the number of meals is

weighted by a predetermined percentage. The number of meal days for a given day is

figured by multiplying the number of breakfast, lunch and dinner meals served by the

factored percentages of 20, 40 and 40 percent, respectively, and totaling the results. If/as

applicable, TIMs are valued at 80%, Ambulatory Procedures Visit (APV)/Same Day Surgery

(SDS) meals at 40%, holiday meals at 65%, and midnight meal at 20%.

86 AFMAN44-144 20 JANUARY 2016

 Are patient meal days appropriately obtained by multiplying the occupied bed days by the

appropriate meal factors?

 Are ESM meal days appropriately obtained by multiplying the number of ESM patrons by

the appropriate meal factors?

 Are cash patron meal days appropriately obtained by multiplying the number of cash patrons

by the appropriate meal factors?

Subsistence Account Reporting and Management:

 For automated operations, are the AF Accounting Spreadsheet and Computrition used to

assist NM managers in overseeing their subsistence account, inventory value, earnings and

collections?

 For manual operations, are the following three manual cost data records and financial reports

used in NM and the MSA Office to determine financial status: AF Form 544, AF Form 541,

and AF Form 546?

 Is AF Form 2573, Diet Census, documented once daily (following procedures printed on the

reverse side of the form) used for workload figures for the number of trays served to patients

on the nursing units and the number and types of therapeutic diets served to patients on the

nursing units?

 On a monthly basis, is the NM Flight submitting their financial data on the appropriate

spreadsheet (reference AFMAN 44-144, Attachment 4 and AFMOA spreadsheet) to the

AFMOA Uniform Business Office, via their Functional Manager? Is NM also providing a

copy of this info/spreadsheet to their MTF MSA Office every month?

 Subsistence account management. Primary indicators to evaluate the financial status of the

NM operation are: earnings less food served, earnings minus purchases, inventory level, and

periodic inventory adjustment.

 Financial Parameters. Does the status of earnings minus issues not exceed (plus or minus)

5% of the average monthly ration earnings at the end of each of the first three quarters of the

FY as annotated on the AF Accounting Spreadsheet? At the end of the FY, do earnings

minus issues not exceed $100.00 or (plus or minus) 2% of the average monthly credit

earnings, whichever is greater?

 FY Close-out. If at the end of the FY, the earnings minus issues on the AF Accounting

Spreadsheet or line 57 of AF Form 544 exceeds (plus or minus) 2% of the average monthly

earnings, did the MTF Commander investigate?