Intern's Name ………Preceptor's Name………
Experience Site………Dates: From ………To………
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Competency Comments
(strength/improvement) Intern's initiative, characteristic, and communication skills:
Demonstrates effective oral & written communication skills Displays self confidence
Gets along with a variety of people and shows concern for others Accepts constructive criticism and uses it for personal development Dresses appropriately
Displays leadership
Appears motivated/interested and seeks out information
Uses time effectively and arrives/leaves work at appropriate time Sets priorities to accomplish tasks
Work Ethic (i.e. Personal phone calls, email and text messages, adjusting work schedule inappropriately, etc.)
Implements current research information to dietetic practice Intern's performance in applying nutrition assessment:
Conducts nutrition screening of patients
Recognizes relevant data of patient collected from medical/diet/social histories and medical progress notes
Performs diet history
Calculates patient’s caloric, protein and fluid needs based on medical condition and level of stress
Understands and utilizes laboratory values of the patient
Reviews and analyzes patient’s drugs for drug/nutrient reactions and GI disturbances
Attends medical rounds and shares nutritional information Intern's performance in applying nutrition diagnosis:
Ability to recognize the nutrition diagnoses and create a problem, etiology, and signs and symptoms (PES) statement according to protocol of the site
Intern's performance in applying nutrition intervention:
Plans and implements nutrition interventions including prescriptions, goals, and evidence based intervention
Refers clients and patients to other professionals and services if needed Intern's performance in applying patient education & counseling skills:
a. Evaluates and identifies patient needs for education:
Educates group sessions Introduced self appropriately
Established rapport and made client feel comfortable Explained purpose of the session
b. Ability to assess diet of the patient:
Asked how many meals and snacks are eaten Estimated size of portions eaten
Evaluated and advised on usual food preparation Discussed food likes and dislikes
1 Use this form to evaluate the intern for medical, surgical, ICU, outpatient, oncology, pediatric, and OB/GYN rotations.
Rating Scale for learning experiences:
5=Outstanding; 4 = Very Good (Needs supervision only 5-10% of the time); 3 = Average; 2 = Improvement Needed (Needs frequent supervision; 1 = Not Observed; N/A = Not Applicable
Clinical Nutrition Department Dietetic Internship Program Intern Performance Evaluation Clinical Rotations
Adjusted diet to meet patient's home and work environment c. Evaluate the intern's listening and communication skills:
Used open-ended questions Listened carefully
Established eye contact
Explained answers appropriately Gave accurate nutritional information
d. Evaluate the intern's performance when concluding the education/counseling session:
Summarized advice and findings for the patient Followed up with patient
Intern's performance in applying nutrition monitoring & evaluation: Monitors and evaluates patient’s food and/or nutrient intake and tolerance of enteral and parenteral formulas
Selects the proper indicators to measure achievement of clinical outcomes
Develops appropriate diet discharge plans for patients according to the patient’s lifestyle and budget and explain it using educational
materials to patients and/or their families
Intern's performance with regards to completing medical record documentation:
Completes documentation of nutrition assessment, nutrition diagnosis, nutrition intervention, and monitoring/evaluation plans
Uses relevant anthropometric, biochemical, clinical and dietary data when identify nutrition problems in PES statements
Utilizes professional writing skills
Intern's performance with regards to nutrition calculations (diet/enteral & parenteral):
Calculates patient’s caloric, protein and fluid needs based on medical condition and level of stress
Selects the proper enteral and/or parenteral formulas to patient considering the medical condition based on recent dietetic practice Monitors the tolerance of enteral and parenteral formulas
Accurately calculates energy and nutrient content of enteral and parenteral formulas
Monitors Implements proper transitional feeding plans
Please comment on the strengths of the intern and areas where the intern needs improvement
Please indicate the number of days the intern was late and/or absent during the rotation. Did the intern make-up all the days that she was absent?
If late or absent, did the intern contact you ahead of time to explain the situation?
Would you hire this intern for employment? (Yes/No) Intern comments:
Signature of Preceptor:………Date:………
Signature of Intern: ………Date: ………
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