Skills Checklist:
Nutrionist/ Dietition

Skills Checklist – Nutritionist/Dietitian

This self-evaluation is for assessing your experience in specific clinical areas. This self-evaluation will not be a determining factor in accepting your application to become an employee of Connected Health Care.

0 = Not Applicable
1 = No Experience
2 = Some Experience
3 = Intermittent Experience
4 = Experienced
5 = Very Experienced

AGE of Patients Cared For:(Required)

	0	1	2	3	4	5
Newborn/Neonatal (birth - 30 days)*
Infant (30 days - 1 year)*
Toddler (1 - 3 years)*
Preschooler (3 - 5 years)*
School Age (5 - 12 years)*
Adolescents (12 - 18 years)*
Young Adults (18 - 39 years)*
Middle Adults (39 - 64 years)*
Older Adults (64+ years)*
Elderly Adults (over 79+ years)*

GENERAL SKILLS(Required)

	0	1	2	3	4	5
Standard Precautions*
Isolation Precautions*
Pediatric Respiratory/Cardiac Arrest*
Adult Respiratory/Cardiac Arrest*
Crash Carts*
Defibrillators*
Patient/Family Education*
Electronic Documentation*
Managing Food-Drug Interactions*
Managing Food-Drug Timing *
Managing Nutrition Therapy Complications*

ASSESSMENT/PATIENT CARE(Required)

	0	1	2	3	4	5
Develop Plan of Treatment*
Document Refusal of Care *
Document Non-Compliance *
Determine Usual or Adjusted Body Weight *
Determine Energy Requirements *
Determine Protein Requirements *
Determine Fluid Requirements *
Determine Electrolyte Requirements *
Determine Fat Requirements *
Determine Micronutrient Requirement*s
Perform Nutrition Education *
Perform Nutrition Assessments *

NUTRITION STATUS(Required)

CONDITIONS/DISEASES AFFECTING NUTRITION(Required)

	0	1	2	3	4	5
Abdominal Wounds and Surgeries*
Abnormal Bleeding*
Acute MI*
Acute Renal Failure*
Alzheimer's Disease*
Anorexia Nervosa*
Aspiration*
Bulimia*
Cancer*
Chronic Diarrhea*
Coma*
Congenital Heart Defects*
Congestive Heart Failure*
COPD*
CVA*
Decubitus*
Diabetes*
Diabetic Ketoacidosis*
Draining Abscesses*
Draining Wounds*
Drug Overdose*
Dysphagia*
Elevated Cholesterol/Triglycerides*
End Stage Renal Disease*
Epiglottitis*
Excessive Alcohol Intake*
Extensive Burns*
Failure to Thrive*
Fever*
Fistulae*
Hemodialysis*
Hepatitis*
HIV/AIDS*
Homelessness/Limited Access to Food*
Hyperemesis*
Infection*
Inflammatory Bowel Disease*
Liver Failure*
Low Blood Sugar*
Major Surgery*
Malabsorption Syndromes*
Mucositis*
Pancreatitis*
Peritoneal Dialysis*
Pregnancy*
Protracted Emesis*
Radiation*
RDS*
Refeeding Syndrome*
Renal Transplants*
Sepsis*
Short Gut Syndrome*
Sickle Cell Anemia*
Status Asthmaticus*
Stomatitis*
Transplants*
Trauma*
Tuberculosis*
Vented Patient*
Wounds*
Morbid Obesity*
Post-Op Gastric Stapling/Gastric Bypass*
Depression*

MEDICATION AFFECTING NUTRITION(Required)

LAB MONITORING(Required)

	0	1	2	3	4	5
LFT's*
Serum Ammonia*
Serum Amylase*
Cholesterol
BUN*
Serum Electrolytes*
Blood Glucose*
Hematology*
Creatinine*
Albumin*
Pre-Albumin*
C-Reactive Proteins*
Nitrogen Balance*
Acid/Base Balance*
Protein-Energy Balance*
Vitamins and Minerals*

MANAGING NUTRITION THERAPY(Required)

SETTINGS(Required)

Name

First Last

Date

Specialty

By Signing this, I am authorizing that the information I have given is true and accurate to the best of my knowledge. I hereby authorize Connected Health Care to release this Skills Checklist to staffing clients of Connected Health Care. Submit this skills evaluation with your initial application.

Signature(Required)

	0	1	2	3	4	5
Clinic Malnutrition*
Poor Diet*
Eating Difficulties*
Marginal Malnutrition*
Metabolic Demands*
Nutrient Deficiencies*
Assess Fluid Status*
Kwashiorkor*
Marasmus*
Cachexia*
Protein Calorie Malnutrition*

	0	1	2	3	4	5
Steroids*
Immunosuppressants*
Antineoplastics*
Insulin*
Diuretics*
Blood Thinners*
Laxatives*

	0	1	2	3	4	5
Oral Diets*
Enteral Nutrition*
Parenteral Nutrition*
Writing Orders for Nutrition*
Intake and Output*
Fluid Balance*
Calorie Counts*
Small Bowel Feeding Tubes*
Gastrostomy Tubes*
Jejunostomy Tubes*

	0	1	2	3	4	5
Hospital*
Clinic*
Long Term Care*
Retirement Center*
Hospice*
Home Health*
Research*
Daycare*
Correctional Facility*
Restaurant*
Public Health*
Community Programs*