[checklist name="Dietician Skills Checklist" mailto="[email protected]" templatedoc="1OUc15TbFrtOHcwpOOBIpJtsYYsEaTa73FBWLy2z9NbY" templatedrive="1LG9WAg21_L3L-ZkZEChBzrYRhBOjpmcc" savedrive="15FFQjDXxe9nC9FkAAcuxbswGy1hq4sWm" sheetid="1xJkggLvktsyYL6zuIhdO-OURJhJTkWdDKunR11agspw" submitto="/wp-content/themes/orange/custom-shortcodes/google-services/functions/google-sheets/addFormGoogleSheetRow.php"] [checklistHeading title="Dietician Skills Checklist"] Please rate your experience/frequency (within the last year) using the scale (check the appropriate boxes below) 0 = No theory and/or experience 1 = Limited experience/need supervision and/or support 2 = Experienced/minimal support needed to perform) 3 = Proficient/can perform independently 4 = Expert/very experienced in the field [/checklistHeading] [checklistInputGroup name="Recruiter Information"] [checklistInput type="text"]Recruiter TEEMA email[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Personal Information"] [checklistInput type="text"]Full Name[/checklistInput] [checklistInput type="email"]Your Email[/checklistInput] [checklistInput type="text"]Your phone number[/checklistInput] [checklistInput type="text"]Last 4 of Social Security Number[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Age of Patients Cared For"] [checklistInput type="scale"]Newborn/Neonate (birth to 30 days)[/checklistInput] [checklistInput type="scale"]Infant (1 month to 1 year)[/checklistInput] [checklistInput type="scale"]Toddler (1 year to 3 years)[/checklistInput] [checklistInput type="scale"]Preschooler (3 years to 5 years)[/checklistInput] [checklistInput type="scale"]School Age Child (5 years to 12 years)[/checklistInput] [checklistInput type="scale"]Adolescents (12 years to 18 years)[/checklistInput] [checklistInput type="scale"]Young Adults (18 years to 39 years)[/checklistInput] [checklistInput type="scale"]Middle Adults (39 years to 64 years) [/checklistInput] [checklistInput type="scale"]Older Adults (64 years to 79 years)[/checklistInput] [checklistInput type="scale"]Elderly Adults (over 70+ years)[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="General Skills"] [checklistInput type="scale"]Standard Precautions[/checklistInput] [checklistInput type="scale"]Isolation Precautions[/checklistInput] [checklistInput type="scale"]Pediatric Respiratory/Cardiac Arrest[/checklistInput] [checklistInput type="scale"]Adult Respiratory/Cardiac Arrest[/checklistInput] [checklistInput type="scale"]Crash Carts[/checklistInput] [checklistInput type="scale"]Defibrillators[/checklistInput] [checklistInput type="scale"]Patient and Family Education[/checklistInput] [checklistInput type="scale"]Electronic Documentation[/checklistInput] [checklistInput type="scale"]Managing Food-Drug Interactions[/checklistInput] [checklistInput type="scale"]Managing Food-Drug Timing[/checklistInput] [checklistInput type="scale"]Managing Nutrition Therapy Complications[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Assessment / Patient Care"] [checklistInput type="scale"]Develop Plan of Treatment[/checklistInput] [checklistInput type="scale"]Document Refusal of Care[/checklistInput] [checklistInput type="scale"]Document Non-Compliance[/checklistInput] [checklistInput type="scale"]Determine Usual or Adjusted Body Weight[/checklistInput] [checklistInput type="scale"]Determine Energy Requirements[/checklistInput] [checklistInput type="scale"]Determine Protein Requirements[/checklistInput] [checklistInput type="scale"]Determine Fluid Requirements[/checklistInput] [checklistInput type="scale"]Determine Electrolyte Requirements[/checklistInput] [checklistInput type="scale"]Determine Fat Requirements[/checklistInput] [checklistInput type="scale"]Determine Micronutrient Requirements[/checklistInput] [checklistInput type="scale"]Perform Nutrition Education[/checklistInput] [checklistInput type="scale"]Perform Nutrition Assessments[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Assessment / Patient Care"] [checklistInput type="scale"]Develop Plan of Treatment[/checklistInput] [checklistInput type="scale"]Document Refusal of Care[/checklistInput] [checklistInput type="scale"]Document Non-Compliance[/checklistInput] [checklistInput type="scale"]Determine Usual or Adjusted Body Weight[/checklistInput] [checklistInput type="scale"]Determine Energy Requirements[/checklistInput] [checklistInput type="scale"]Determine Protein Requirements[/checklistInput] [checklistInput type="scale"]Determine Fluid Requirements[/checklistInput] [checklistInput type="scale"]Determine Electrolyte Requirements[/checklistInput] [checklistInput type="scale"]Determine Fat Requirements[/checklistInput] [checklistInput type="scale"]Determine Micronutrient Requirements[/checklistInput] [checklistInput type="scale"]Perform Nutrition Education[/checklistInput] [checklistInput type="scale"]Perform Nutrition Assessments[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Nutrition Status"] [checklistInput type="scale"]Clinic Malnutrition[/checklistInput] [checklistInput type="scale"]Poor Diet[/checklistInput] [checklistInput type="scale"]Eating Difficulties[/checklistInput] [checklistInput type="scale"]Marginal Malnutrition[/checklistInput] [checklistInput type="scale"]Metabolic Demands[/checklistInput] [checklistInput type="scale"]Nutrient Deficiencies[/checklistInput] [checklistInput type="scale"]Assess Fluid Status[/checklistInput] [checklistInput type="scale"]Kwashiorkor[/checklistInput] [checklistInput type="scale"]Marasmus[/checklistInput] [checklistInput type="scale"]Cachexia[/checklistInput] [checklistInput type="scale"]Protein Calorie Malnutrition[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Conditions / Diseases Affecting Nutrition"] [checklistInput type="scale"]Abdominal Wounds and Surgeries[/checklistInput] [checklistInput type="scale"]Abnormal Bleeding[/checklistInput] [checklistInput type="scale"]Acute MI[/checklistInput] [checklistInput type="scale"]Acute Renal Failure[/checklistInput] [checklistInput type="scale"]Alzheimer's Disease[/checklistInput] [checklistInput type="scale"]Anorexia Nervosa[/checklistInput] [checklistInput type="scale"]Aspiration[/checklistInput] [checklistInput type="scale"]Bulimia[/checklistInput] [checklistInput type="scale"]Cancer[/checklistInput] [checklistInput type="scale"]Chronic Diarrhea[/checklistInput] [checklistInput type="scale"]Coma[/checklistInput] [checklistInput type="scale"]Congenital Heart Defects[/checklistInput] [checklistInput type="scale"]Congestive Heart Failure[/checklistInput] [checklistInput type="scale"]COPD[/checklistInput] [checklistInput type="scale"]CVA[/checklistInput] [checklistInput type="scale"]Decubitus[/checklistInput] [checklistInput type="scale"]Diabetes[/checklistInput] [checklistInput type="scale"]Diabetic Ketoacidosis[/checklistInput] [checklistInput type="scale"]Draining Abscesses[/checklistInput] [checklistInput type="scale"]Draining Wounds[/checklistInput] [checklistInput type="scale"]Drug Overdose[/checklistInput] [checklistInput type="scale"]Dysphagia[/checklistInput] [checklistInput type="scale"]Elevated Cholesterol/Triglycerides[/checklistInput] [checklistInput type="scale"]End Stage Renal Disease[/checklistInput] [checklistInput type="scale"]Epiglottitis[/checklistInput] [checklistInput type="scale"]Excessive Alcohol Intake[/checklistInput] [checklistInput type="scale"]Extensive Burns[/checklistInput] [checklistInput type="scale"]Failure to Thrive[/checklistInput] [checklistInput type="scale"]Fever[/checklistInput] [checklistInput type="scale"]Fistulae[/checklistInput] [checklistInput type="scale"]Hemodialysis[/checklistInput] [checklistInput type="scale"]HIV/AIDS[/checklistInput] [checklistInput type="scale"]Homelessness/Limited Access to Food[/checklistInput] [checklistInput type="scale"]Hyperemesis[/checklistInput] [checklistInput type="scale"]Infection[/checklistInput] [checklistInput type="scale"]Inflammatory Bowel Disease[/checklistInput] [checklistInput type="scale"]Liver Failure[/checklistInput] [checklistInput type="scale"]Low Blood Sugar[/checklistInput] [checklistInput type="scale"]Major Surgery[/checklistInput] [checklistInput type="scale"]Malabsorption Syndromes[/checklistInput] [checklistInput type="scale"]Mucositis[/checklistInput] [checklistInput type="scale"]Pancreatitis[/checklistInput] [checklistInput type="scale"]Peritoneal Dialysis[/checklistInput] [checklistInput type="scale"]Pregnancy[/checklistInput] [checklistInput type="scale"]Protracted Emesis[/checklistInput] [checklistInput type="scale"]Radiation[/checklistInput] [checklistInput type="scale"]RDS[/checklistInput] [checklistInput type="scale"]Refeeding Syndrome[/checklistInput] [checklistInput type="scale"]Renal Transplants[/checklistInput] [checklistInput type="scale"]Sepsis[/checklistInput] [checklistInput type="scale"]Short Gut Syndrome[/checklistInput] [checklistInput type="scale"]Sickle Cell Anemia[/checklistInput] [checklistInput type="scale"]Status Asthmaticus[/checklistInput] [checklistInput type="scale"]Stomatitis[/checklistInput] [checklistInput type="scale"]Transplants[/checklistInput] [checklistInput type="scale"]Trauma[/checklistInput] [checklistInput type="scale"]Tuberculosis[/checklistInput] [checklistInput type="scale"]Vented Patient[/checklistInput] [checklistInput type="scale"]Wounds[/checklistInput] [checklistInput type="scale"]Morbid Obesity[/checklistInput] [checklistInput type="scale"]Post-Op Gastric Stapling/Gastric Bypass[/checklistInput] [checklistInput type="scale"]Depression[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Medications Affecting Nutrition"] [checklistInput type="scale"]Steroids[/checklistInput] [checklistInput type="scale"]Immunosuppressants[/checklistInput] [checklistInput type="scale"]Antineoplastics[/checklistInput] [checklistInput type="scale"]Insulin[/checklistInput] [checklistInput type="scale"]Diuretics[/checklistInput] [checklistInput type="scale"]Blood Thinners[/checklistInput] [checklistInput type="scale"]Laxatives[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Medications Affecting Nutrition"] [checklistInput type="scale"]Steroids[/checklistInput] [checklistInput type="scale"]Immunosuppressants[/checklistInput] [checklistInput type="scale"]Antineoplastics[/checklistInput] [checklistInput type="scale"]Insulin[/checklistInput] [checklistInput type="scale"]Diuretics[/checklistInput] [checklistInput type="scale"]Blood Thinners[/checklistInput] [checklistInput type="scale"]Laxatives[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Lab Monitoring"] [checklistInput type="scale"]LFT's [/checklistInput] [checklistInput type="scale"]Serum Ammonia [/checklistInput] [checklistInput type="scale"]Serum Amylase[/checklistInput] [checklistInput type="scale"]Cholesterol[/checklistInput] [checklistInput type="scale"]BUN[/checklistInput] [checklistInput type="scale"]Serum Electrolytes [/checklistInput] [checklistInput type="scale"]Blood Glucose [/checklistInput] [checklistInput type="scale"]Hematology [/checklistInput] [checklistInput type="scale"]Creatinine [/checklistInput] [checklistInput type="scale"]Albumin[/checklistInput] [checklistInput type="scale"]Pre-Albumin [/checklistInput] [checklistInput type="scale"]C-Reactive Proteins[/checklistInput] [checklistInput type="scale"]Nitrogen Balance[/checklistInput] [checklistInput type="scale"]Acid/Base Balance[/checklistInput] [checklistInput type="scale"]Protein-Energy Balance[/checklistInput] [checklistInput type="scale"]Vitamins and Minerals[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Managing Nutrition Therapy"] [checklistInput type="scale"]Oral Diets[/checklistInput] [checklistInput type="scale"]Enteral Nutrition[/checklistInput] [checklistInput type="scale"]Parenteral Nutrition[/checklistInput] [checklistInput type="scale"]Writing Orders for Nutrition[/checklistInput] [checklistInput type="scale"]Intake and Output[/checklistInput] [checklistInput type="scale"]Fluid Balanace [/checklistInput] [checklistInput type="scale"]Calorie Counts[/checklistInput] [checklistInput type="scale"]Small Bowel Feeding Tubes[/checklistInput] [checklistInput type="scale"]Gastrostomy Tubes[/checklistInput] [checklistInput type="scale"]Jejunostomy Tubes[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Settings"] [checklistInput type="scale"]Hospital[/checklistInput] [checklistInput type="scale"]Clinic[/checklistInput] [checklistInput type="scale"]Long Term Care [/checklistInput] [checklistInput type="scale"]Retirement Center [/checklistInput] [checklistInput type="scale"]Hospice[/checklistInput] [checklistInput type="scale"]Home Health [/checklistInput] [checklistInput type="scale"]Research[/checklistInput] [checklistInput type="scale"]Daycare [/checklistInput] [checklistInput type="scale"]Correctional Facility [/checklistInput] [checklistInput type="scale"]Restaurant[/checklistInput] [checklistInput type="scale"]Public Health[/checklistInput] [checklistInput type="scale"]Community Programs[/checklistInput] [/checklistInputGroup] [checklistFooter] [/checklistFooter] [/checklist]