Clinical Staff Relief Performance Evaluation Form. Intern Name. Rotation Site. Rotation Dates to. Preceptor. Date of evaluation

Transcription

1 Intern Name Rotation Site Rotation Dates to Preceptor Date of evaluation Please check: Mid-point Evaluation Final Evaluation Please check: Preceptor-Evaluation Intern-Evaluation This form is divided into three sections based on the skills which the intern develops to become an entry level dietitian. Please record the numeric value (1-6) for each objective using the rating scale provided at the top of each page. Space is provided after each objective for additional comments and explanation. If either the intern or preceptor feels there was no opportunity to observe an objective, N/A should be written in the space allotted for checking the rating scale. The performance evaluation is used at both the middle and end of the clinical experience. The evaluation given at mid-point will include Section III where appropriate. This will encourage discussion about the intern s increasing responsibility towards assuming the staff relief role. The mid-point evaluation will provide guidance for the intern and will not count toward the competency score 1. The final evaluation will be a major consideration for the score the intern receives on the following competencies: CD 3.1, 3.1.a, 3.1.b, 3.1.c, 3.1.d, 3.5, and The intern should evaluate himself/herself before meeting with the preceptor. The preceptor should also complete his/her evaluation of the intern before the evaluation meeting. At the time of evaluation, discrepancies should be discussed. 1 It should be expected that for the beginning intern, the level of achievement for most of the objectives will not be above 3 or 4 on the rating scale at the mid-point evaluation.

2 SECTION I: Patient Interviewing and Counseling 1. identifies patient and self by name, using appropriate title. 2. establishes rapport with patient. 3. identifies purpose of session. 4. evaluates patient's knowledge of condition, including information and instruction from other professionals. 5. gears sessions to level of patient's understanding. 6. suppresses own feelings concerning food preferences. 7. assesses patient's understanding and acceptance of instruction at intervals and responds accordingly. 8. includes appropriate family members when feasible. 9. obtains information needed to formulate a nutrition care plan. 10. exhibits understanding of diet in relations to medical condition. 11. explains reasons for diet modification. 12. encourages patient to help in development of diet. 13. individualizes diet instruction to patient's needs, including nutritional, medical, socio-economic, cooking, and storage capabilities.

3 14. utilizes knowledge gained from medical records and other professionals. 15. gives accurate information. 16. conducts a well organized instruction. 17. refers patient to other professional services if needed. 18. determines when to terminate interview and informs patient as to where interviewer can be reached. 19. records pertinent information in appropriate records. 20. provides for appropriate nutritional follow-up. Total Score SECTION II: Use of Medical Records 1. exhibits understanding of common medical terminology. 2. exhibits understanding of chart organization. 3. identifies pertinent laboratory data and makes appropriate assessments.

4 4. utilizes other professional's notes. 5. is accurate, concise and legible when recording in patient medical record. 6. documents pertinent information in medical record note using appropriate format. Total Score SECTION III: Demonstration of Ability to Function as Staff Member Attitude 1. is open to new ideas. 2. exhibits a pleasant attitude toward work, employees and supervisors. 3. is motivated and responsive. 4. follows directions from immediate supervisor. Judgment 5. screens and categorizes patients in appropriate nutrition risk categories.

5 6. assesses appropriateness of diet prescription and patient's need for education. 7. prioritizes patients who require nutrition intervention. 8. identifies all appropriate aspects of nutrition treatment necessary for an individual patient. 9. is accurate in judgment decisions. Time Management 10. demonstrates ability to set priorities and organize time. 11. counsels patients on medical nutrition therapy in a timely manner. 12. completes patient progress notes/documentation within suggested time frame. Total Score