usu cLrNrcAL FINAL EVATUATTON #15 IGLINIGAL F|NAL EVALUATTON (#15)

Please evaluate the student/intern on the following areas ofPlease circle the number corresponding to your rating

Scale: 1- Very weak, needs more work2 - weak, needs more work3 - doing well, performing as expected for student/intern level4 - above average, doing better than expected5 - outstanding, doing much better than expected for levelN/A - not applicable to this rotation

. Add comments in each area for particularly strong or weak performance

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D"t" {f(l&Student/l ntern

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PROFESSIONALISM 1 12 13 14) ls lN/AcRD 2.11 Aoorooriate dress and groomins Comments

cRD 2.11 Attitude of learnine and willinsness to workcRD 2.1, 2.10 Appropriate interaction with patients/clients/staff

RESPONSIBILIW 1 12 13 lA) ls lNlAcRD 2.11 Punctual with aoorooriate tools Comments

cRD 2.1r- Follows throueh with responsibilities

cRD 2.1.1 AooroDriatelv takes initiative in solvins oroblems

cRD 2.11 AcceDts conseouences of actions

cRD 2.12 Able to set and accomplish objectives

cRD 2.12 Able to evaluate own strensths and weaknesses

TIME MANAGEMENT 1 12 13 14 {s) lN/AcRD 2.11 Sets priorities Comments W _J.t"rC c^ 1,-z-*,troV Z.

CJ-JJ* ,n.L.Z r'r^a1ecRD 2.11 Handles increasinq work load

RESOURCE MANAGEMENT 1 '12 Y3 lr4) ls lN/AcRD 1.2, 7.3,2.7 Utilizes reference materials; current techniques Comments

cRD 4.5 Appropriately uses information technology to retrieve,store, and disseminate information or data

cRD 1.2, L.3,2.8,3.1c

Able to justify/support decisions with correctinformation

cRD 2.7,2.!t,2.13

Consults with preceptor/instructor; acts within level ofcomt}elrrnce

cRD 1.2, L.3, t.4,2.4,3.la-e

Has and uses adequate knowledge base

NCP: ASSESSMENT, MONITORING, EVAIUATION 1 l2 13 lf4/ ls lN/ACRD 2.5, 3.1a,4.5 Completes screening procedures Comments

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CRD 3.1a, 3.1d History nutrition, personal, medical, familv, social

CRD 3.1a, 3.1d Food and nutrient intake, access to foodCRD 3.1a. 3.1d Medications, supplements

CRD 3.1a, 3.1d Pt/client knowledge, belief, attitude, behaviors towardsnutrition related concepts

CRD 3.1a, 3.1d Anthropometric measurements, assessments

CRD 3.1a, 3.1d Biochemical data, medical test, procedures

CRD 3.1a, 3.1d Nutrition focused physical findings (wasting,

suck/swallow, etc.)

CRD 3.1a, 3.1d Compare nutrient and growth needs to standards

{energy, pro, fluid, growth, etc.). Accurate needscalculations

cRD 3.ld, 3.6 Monitor intake of patient po, enteral, parenteral feeds.Evaluate and make aooroDriate chanses.

-usu cLrNrcAL FrNAr EVALUATTON #15 I

NCPr DIAGNOSIS 1 12 f3) lq ls lN/AcRD 3.1b ldentifu and label nutrition problems, etiology, and

signs and symptomsComments

NCP: INTERVENTION 1 12 {3\ lc ls lN/AcRD 1.2,3.1a,3.1c

lmplement conversion of one form of nutrition supportto another. lmplement changes in feeding from ECF orhome

Comments

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CRD 3.la, 3.1c Able to interpret data collectedCRD 3.1c, 3.1d Accurate diet/oral supplement/ calorie count

calculations

CRD 3.1c Checks work for errors

CRD 3.1c Appropriate, accurate nutrition supportrecommendations

cRD 2.4, 2.10,3.Ic.3.4

Appropriate, accurate, completeinstructional/counseline materials and methods

CRD 3.1c, 2.4 Appropriate teaching level for ptfamily understanding;familv involvement

CRD 3.1c, 3.1d Evaluates, ot/client's level of understandins. motivationcRD 2.7,3.!c,2.$

Establishes, coordinates, implements follow up careshort and/or lons-term

cRD 2.5,2.7,3.1c Appropriate involvement and coordination with healthcare for nutrition interventions

cRD 4.11 Participates in codinglbilling of dietetics/nutritionservices

COMMUNICATION 1 l2 13 tG) ts tN/AcRD 2.13 Uses proper channels of communication CommentscRD 2.11 Listens activelv

cRD 2.2. 3.2, 3.1c Appropriate written and oral communicationCRD 3.1e,4.5 Completes documentation that follows professional

guidelines required bv practice settingcRD 2-1 Maintains confidentialitvcRD 2.11,2.13 Culturallv sensitive

cRD 2.5 Active particioation in team conferencescRD 1.4, 3.4 Utilizes current research in formal presentations to

professionals and interactions with pt/clients

Please comment on the student/intern's overall performance:Strengths:

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Areas for further work:

PreceOtor: hudent/lntern

usu clrNrcAr F|NAL EVALUATION #15 I

cLrNrcAL F|NAL EVALUATION (#15)

\\r.\ ' ^Facility T(c\- Jor Ar\o Date

preceptor \t*.".'\i zonr -I-lu\ student/lntern \ '\*\-'*- t'q-e

Please evaluate the student/intern on the following areas of performance

Please circle the number corresponding to your rating

Scale: 1 - Very weak, needs more work2 - weak, needs more work3 - doing well, performing as expected for student/intern level

4 - above average, doing better than expected

5 - outstanding, doing much better than expected for level

N/A - not applicable to this rotation

o Add comments in each area for particularly strong or weak performance

a

a

PROFESSIONALISM 7 2 3 t 4 t{s' N/A

cRD 2.11 Appropriate dress and grooming Comments

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cRD 2.11 Attitude of learnins and willingness to work

cRD 2.1, 2.10 Aoorooriate interaction with patients/clients/staff

RESPONSIBILITY r lz 13 la lr.s') lN/AcRD 2.11 Punctual with appropriate tools Comments

cRD 2.11 Follows through with responsibilities

cRD 2.11 Aopropriatelv takes initiative in solving problems

cRD 2.11 Accepts consequences of actions

cRD 2.12 Able to set and accomplish objectives

cRD 2.12 Able to evaluate own strengths and weaknesses

TIME MANAGEMENT 1 12 13 14 \s) lN/AcRD 2.11 Sets priorities Comments

cRD 2.1r. Handles increasins work load

RESOURCE MANAGEMENT 1 12 l3 14 l\s\ lN/AcRD t.2, L.3,2.1. Utilizes reference materials; current techniques Comments

cRD 4,5 Appropriately uses information technology to retrieve,

store, and disseminate information or data

cRD 1.2, t.3,2.8,3.1c

Able to justify/support decisions with correctinformation

cRD 2.1,2.r1.2.r3

Consults with preceptor/instructor; acts within level ofcompetence

cRD 1.2, 7.3, L.4,

2.4.3.ta-eHas and uses adequate knowledge base

NCP: ASSESSMENT MONITORING, EVALUATION 7 l2 3 l\4 ls lN/ACRD 2.6. 3.1a.4.5 Completes screening procedures Comments

CRD 3.la,3.1d Historv nutrition, personal, medical, familv, social

CRD 3.1a,3.1d Food and nutrient intake, access to food

CRD 3.1a,3.1d Medications, supplements

CRD 3.1a,3.1d Pt/client knowledge, belief, attitude, behaviors towardsnutrition related concepts

CRD 3.1a, 3.ld Anthrooometric measurements, assessments

CRD 3.la.3.1d Biochemical data, medical test, procedures

CRD 3.1a, 3.1d Nutrition focused physical findings (wasting,

suck/swallow. etc.)

CRD 3.1a, 3.1d Compare nutrient and growth needs to standards(energy, pro, fluid, growth, etc.). Accurate needs

calculations

cRD 3.1d, 3.6 Monitor intake of patient po, enteral, parenteral feeds.

Evaluate and make appropriate changes.

usu cLrNrcAL FINAL EVALUATTON #15 INCP: DIAGNOSIS T l2 l3 l4 l\s 4 I N/A

cRD 3.1b ldentify and label nutrition problems, etiology, and

signs and symptoms

Comments

NCP: INTERVENTION 1 l2 l3 t\4 ts lMDllcRD 1.2, 3.la,3.1c

lmplement conversion of one form of nutrition supportto another. lmBlelnent changes in feeding from ECF orhome 0.J l{

Comments YCRD 3.1a, 3.1c Able to interpret data collected

CRD 3.1c, 3.1d Accurate diet/oral supplement/ calorie count

calculations

CRD 3.1c Checks work for errors

CRD 3.1c Appropriate, accurate nutrition supportrecommendations

cRD2.4,2.70,3.1c, 3.4

Appropriate, accurate, completeinstructional/counseling materials and methods

CRD 3.1c, 2.4 Appropriate teaching level for ptlfamily understanding;

family involvementCRD 3.1c.3.1d Evaluates, pt/client's level of understanding, motivation

cRD 2.7,3.tc,2.t0

Establishes, coordinates, implements follow up care

short and/or lons-termcRD 2.6, 2.7,3.Ic Appropriate involvement and coordination with health

care for nutrition interventionscRD 4.11 Participates in coding/billing of dietetics/nutrition

services

COMMUNICATION 1 12 l3 14 \sl) lN/AcRD 2.13 Uses Drooer channels of communication Comments

cRD 2.11 Listens activelv

cRD 2.2, 3.2,3.1.c Appropriate written and oral communication

CRD 3.1e,4.5 Completes documentation that follows professional

euidelines required bv practice setting

cRD 2.1 Maintains confidentialitycRD 2.11.2.L3 Culturallv sensitive

cRD 2.5 Active participation in team conferences

cRD 1.4, 3.4 Utilizes current research in formal presentations tonrofessionals and interactions with ptlclients

Please comment on the student/intern's overall performance:strensths:

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Areas for further work:

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