Clinical Staff Relief Performance Evaluation Form - Concordia College Dietetic Internship

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Concordia College Dietetic Internship
Clinical Staff Relief Performance Evaluation Form
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
1
provide guidance for the intern and will not count toward the competency score
.
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 4.11.
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.
Updated June 2014
Concordia College Dietetic Internship
Clinical Staff Relief Performance Evaluation Form
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
1
provide guidance for the intern and will not count toward the competency score
.
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 4.11.
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.
Updated June 2014
Concordia College Dietetic Internship
Clinical Staff Relief Performance Evaluation Form
1 - 2 Needs Assistance
to Achieve Objective
Meets Objective:
3 - 4 Most of the Time
5 - 6 Consistently
The intern:
1
2
3
4
5
6
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.
Updated June 2014
Concordia College Dietetic Internship
Clinical Staff Relief Performance Evaluation Form
1 - 2 Needs Assistance
to Achieve Objective
Meets Objective:
3 - 4 Most of the Time
5 - 6 Consistently
The intern:
1
2
3
4
5
6
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.
Comments:
Total Score _______
The intern:
1
2
3
4
5
6
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.
Updated June 2014
Concordia College Dietetic Internship
Clinical Staff Relief Performance Evaluation Form
1 - 2 Needs Assistance
to Achieve Objective
Meets Objective:
3 - 4 Most of the Time
5 - 6 Consistently
The intern:
1
2
3
4
5
6
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.
Comments:
Total Score_________
SECTION III: Demonstration of Ability to Function as Staff Member
Attitude
The intern:
1
2
3
4
5
6
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.
Updated June 2014
Concordia College Dietetic Internship
Clinical Staff Relief Performance Evaluation Form
1 - 2 Needs Assistance
to Achieve Objective
Meets Objective:
3 - 4 Most of the Time
5 - 6 Consistently
The intern:
1
2
3
4
5
6
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.
Comments:
Total Score_________
Updated June 2014

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