Dietician Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

GENERAL SKILLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Advanced directives	123
HIPAA Regulations	123
National Patient Safety Goals	123
Awareness of HCAHPS scores	123
Universal Precautions	123
Infection control/ handwashing	123
Isolation techniques	123
Fall Risks	123
Electronic Medical Record	123
Accurate Patient Identification	123
Adult Respiratory /Cardiac Arrest	123
Pediatric Respiratory Cardiac Arrest	123
Patient/ Family Education	123

MANAGING NUTRITION THERAPY:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Calorie Count	123
Enteral Nutrition	123
Fluid Balance	123
Intake and Output	123
Managing Food-Drug Interactions	123
Managing Nutrition Therapy Complications	123
Oral Diets	123
Parenteral Nutrition	123
Ng Tubes	123
Gastrostomy Tubes	123
Jejunostomy Tubes	123
Small Bowel Feeding Tubes	123

NUTRITIONAL STATUS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Assess Fluid status	123
Cachexia	123
Clinical Malnutrition	123
Eating Difficulties	123
Kwashiorkor	123
Marginal Malnutrition	123
Metabolic Demands	123
Marasmus	123
Nutrient Deficiency	123
Poor Diet	123
Protein Calorie Malnutrition	123

DISEASES/CONDITIONS AFFECTING NUTRITION:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Asthma	123
Abdominal Wounds and Surgeries	123
Abnormal Bleeding	123
Acute MI	123
Acute Renal Failure	123
Alzheimer's Disease	123
Anorexia Nervosa	123
Aspiration	123
Bowel Disease	123
Bulimia	123
Burns	123
Cancer	123
Chronic Diarrhea	123
Cholesterol	123
Coma	123
Congenital Heart Defects	123
Congestive Heart Failure	123
COPD	123
CVA	123
Decubitus, wounds	123
Depression	123
Diabetes	123
Diabetic Ketoacidosis	123
Drug Overdose	123
Dysphagia	123
End Stage Renal Disease	123
Epiglottitis	123
Excessive Alcohol Intake	123
Failure to Thrive	123
Gastric Bypass	123
Fever	123
Fistulae	123
Hemodialysis	123
Liver Failure	123
Hepatitis	123
HIV/AIDS	123
Hyperemesis	123
Infection	123
Hypoglycemia/ Hyperglycemia	123
Malabsorption Conditions	123
Morbid Obesity	123
Mucositis	123
Pancreatitis	123
Peritoneal Dialysis	123
Pregnancy	123
Protracted Emesis	123
Radiation	123
Sepsis	123
Sickle Cell Anemia	123
Stomatitis	123
Transplant Patients	123
Trauma	123
Tuberculosis	123
Vented/Sedated patients	123

ASSESSMENT PATIENT CARE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Develop Plan of Treatment	123
Determine Usual or Adjusted Body Weight	123
Determine Energy Requirements	123
Determine Electrolyte Requirements	123
Determine Fat Requirements	123
Determine Protein Requirements	123
Determine Micronutrient Requirements	123
Document non-compliance	123
Develop and Perform Nutrition Education	123
Perform Nutrition Assessments	123

MEDICATIONS AND EFFECTS ON NUTRITIONAL STATUS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Antineoplastics	123
Anticoagulants	123
Diuretics	123
Immunosuppressants	123
Insulin	123
Laxatives	123

LAB MONITORING:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Albumin/ Pre-Albumin	123
Ammonia (serum)	123
Acid-Base Balance	123
Amylase (serum)	123
BUN	123
Creatinine	123
C-Reactive Protein	123
Cholesterol	123
Electrolytes (serum)	123
Hematology Panel	123
LFT Panel	123
Nitrogen	123
Vitamins and Minerals	123

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Hospital	123
Clinic	123
Correctional Facility	123
Urgent care	123
Long-Term Care/ Skilled Nursing	123
Hospice	123
Home Health	123

AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Newborn / neonate (birth-30 days)	123
Infant (31 days-1 year)	123
Toddler (ages 2-3 years)	123
Preschool (ages 4-5 years)	123
School age (ages 6-12 years)	123
Adolescent (ages 13-21 years)	123
Young adult (ages 22-39 years)	123
Adult (ages 40-64 years)	123
Older adult (ages 65-79 years)	123
Elderly (ages 80+ years)	123

Attestation

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *