LPD_IPD 2011 Department of Nutrition and Dietetics Faculty of Medicine and Health Sciences Universiti Putra Malaysia

ASSESSMENT FORM
(In-patient placement) Students name Matric No. Dietitians name Institution : ____________________________ : ____________________________ : ____________________________ : ____________________________ 3 Satisfactory 4 Good 5 Excellent

Scales of assessment 1 2 Limited skill Needs improvement

* Please note: Assessment should be done at week 8 of the placement. Completed assessment form should be sealed and returned immediately to Department of Nutrition & Dietetics, Faculty of Medicine & Health Sciences, UPM.

A. SKILLS DEVELOPMENT
Assessment criteria a. b. c. d. e. f. g. h. i. j. k. Punctuality in attending clinical placement & assignment. Understand medical and nutrition diagnosis of the cases. Ability to interpret biochemical profile of the case. Ability to perform appropriate anthropometry assessment. Sufficient knowledge in case management. Confidence level in case management. Ability to interview patient to obtain relevant diet-related information. Ability to work in group. Writing skill using SOAP format Body language @ non verbal communication Time management Score Comments (if any)

Total score (A)

B. MANAGEMENT OF THERAPEUTIC DIET

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Assessment criteria

Score

Comments (if any)

a. b.

Ability to modify normal diet to therapeutic diet according to patients conditions. Competency in planning appropriate enteral nutrition support regime. (if applicable)

Total score (B)

C. PATIENT MANAGEMENT
Assessment criteria

Score

Comments (if any)

a. b. c. d. e. f. g. h. i.

Understand and able to relate laboratory data/ diagnostic procedure with patients conditions. Ability to conduct diet recall/diet history and assess patients dietary intake Ability to obtain relevant and specific information from patients or caregivers. Ability to determine nutritional status of patients. Ability to determine patients dietary requirement. Ability to deliver dietary recommendation and modification according to patients nutritional status and disease condition. Ability to modify diet recommendations according to patients progress. Ability to work with health care team members Ability to prioritize dietary management for multicomplication/co-morbidity.

Total score (C)

D. COUNSELING
Assessment criteria

Score

Comments (if any)

a. c. d. e.

Appropriate eye contact and intonation during counseling process. Ability to deliver dietary counseling systematically. Ability to provide practical dietary advice according to patients background (socioeconomic & culture). Ability to involve caregiver in the counseling process (if necessary).

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Total score (D)

Overall scores (A+B+C+D)

Overall comments:

Dietitians Signature and Date ____________________________