DIGNITY HEALTH DI AGREEMENT.PDF

DIETITIAN OBSERVER AGREEMENT
THIS DIETITIAN OBSERVER AGREEMENT ("Agreement") is made and entered into on the
later of August 1, 2014, or the last date signed below by a party (“Effective Date”), by and between
DIGNITY HEALTH, a California nonprofit public benefit corporation d/b/a ST. JOSEPH’S
HOSPITAL AND MEDICAL CENTER ("SJHMC”), MERCY GILBERT MEDICAL
CENTER (“MGMC”) and CHANDLER REGIONAL MEDICAL CENTER (“CRMC”)
(SJHMC, MGMC and CRMC are each a “Hospital” and collectively referred to as “Hospital”),
and the MARICOPA COUNTY, BY AND FOR ITS DEPARTMENT OF PUBLIC HEALTH
(“DPH”) with reference to the following facts:
R EC I T A L S
WHEREAS, Hospital is an acute care facility employing registered dietitians;
WHEREAS, DPH conducts a training program for public health dietician interns (each an
“Intern”) who wish to fulfill certain training requirements through observing registered dietitians at
one or more Hospitals;
WHEREAS, Hospital is willing to accept an Intern as “Observers Only”; and
WHEREAS, the parties agree that it is in the mutual interest and benefit of both parties that
Intern obtains a part of his or her professional training experience at Hospital as an “Intern
Observer.”
NOW, THEREFORE, in consideration of the foregoing and the mutual covenants set forth
below, the parties agree as follows:
1. DPH REQUIREMENTS
1.1 Policies and Procedures. DPH understands, and shall ensure that Intern’s
experience at Hospital complies with the respective Hospital’s Policies and Procedures as more
specifically defined below:
(a) As an Arizona State licensed hospital, Hospital is obligated to comply
with state and federal laws regarding licensing requirements for health care personnel who
participate in health care services at Hospital. Therefore, Intern shall comply with all Hospital
policies and procedures regarding compliance with Arizona State laws governing the
performance of clinical services at Hospital.
(b) Recognizing that Intern shall at all times be an Intern Observer without
participation in hands on clinical activity at the Hospital, Intern assumes responsibility to observe
the rules and regulations of Hospital, taking no action that may prove detrimental to Hospital or
its patients.
(c) Intern shall comply with Hospital’s applicable Bylaws, Rules and
Regulations, policies, procedures and guidelines, state and federal laws and regulations.
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(d) Intern shall participate, to the extent scheduled or otherwise requested by
Hospital, in activities and assignments that are of educational value and that are appropriate to
the Intern’s professional background and experience, and are limited to observer activity only.
(e) Intern shall satisfy the responsibilities, as listed in Exhibit A, which is
incorporated herein by this reference. Intern shall also sign the attached “Confidentiality
Statement,” which is attached as Exhibit B and incorporated herein by this reference. Intern
must present signed copies of Exhibits A and B upon commencement of the Intern Observer
experience at Hospital.
1.2 No Compensation. DPH understands and agrees that the Intern Observer
experience at Hospital is to be conducted without payment by either party to the other party.
1.3 Criminal Background Check. DPH shall conduct a criminal background
check to include as a minimum, a state and county criminal history investigation and a state sex
offender search where the Intern resides prior to Intern’s participation in the Intern Observer
experience. Any criminal history identified shall be reported by DPH to Hospital prior to
Intern’s participation in the Intern Observer experience.
2. RESPONSIBILITIES SPECIFIC TO HOSPITAL
Hospital responsibilities shall be as follows:
2.1 Objectives. Hospital shall permit observation to achieve the objectives listed in
Exhibit C, which is incorporated herein by this reference.
2.2 Patient Care Services. Hospital shall retain full responsibility for patient care
and management of related services.
2.3 Staff Coordinator. Hospital shall designate a member of its staff (“Staff
Coordinator”) to provide coordination and oversight of Intern’s educational activities and
assignments while at Hospital. The designated Staff Coordinator shall act as a liaison to the
Intern, providing him or her with appropriate information related to Hospital Policies and
Procedures and other applicable information to guide Intern in the Intern Observer experience.
2.4 HIPAA Compliance. The parties acknowledge that Hospital is obligated to
comply with applicable provisions of the Health Insurance Portability and Accountability Act of
1996 and the rules and regulations promulgated thereunder (“HIPAA”) and privacy and security
policies and procedures related to individually identifiable patient health information (“PHI”).
Hospital agrees to provide Intern with function-specific, HIPAA-related education during the
period when Intern is participating in the Intern Observer experience at Hospital. DPH shall
ensure that Intern complies with Hospital’s policies and procedures governing the protection of
confidentiality of individually identifiable patient health information.
2.5 Emergency Care. Hospital shall provide Intern with any necessary emergency
health care or first aid for accidents occurring at Hospital if, in Hospital’s sole discretion, such
emergency health care or first aid is appropriate under the circumstances. Intern shall be
responsible for paying Hospital charges for such care.
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3. TERM AND TERMINATION
3.1 Term. The term of this Agreement shall commence on the Effective Date, as
first set forth above, and shall continue through July 31, 2019, or until earlier terminated as
provided herein (the “Expiration Date”).
3.2 Termination. This Agreement may be terminated in accordance with the
following provisions:
(a) Either party may terminate this Agreement for any reason by furnishing
the other party with ten (10) days prior written notice of such termination.
(b) In the event of material breach, the aggrieved party may terminate this
Agreement; provided, however, the termination for the breach will not become effective unless
and until the party not in breach has given the other party written notice of breach, which notice
shall state the general nature of the breach, and the party allegedly in breach shall thereafter have
a period of ten (10) days following the giving of notice in which to remedy the breach to the
reasonable satisfaction of the other party. Where a material breach is not remedied within the
time limit specified above, termination for cause is effective immediately after the ten-day (10-
day) period allowed for remedy of the breach.
4. RELATIONSHIP OF PARTIES
The relationship between Hospital and DPH is one of independent contractors. None of the
provisions of this Agreement shall be construed to create a relationship of agency,
representation, joint venture, ownership, control or employment between the parties other than
that of independent parties contracting for the purpose of effecting this Agreement. It is
understood that DPH or Intern shall have no claim under this Agreement against Hospital for
vacation pay, sick leave, retirement benefits, social security, workers' compensation, disability or
unemployment insurance benefits, or employee benefits of any kind.
5. SUSPENSION OR TERMINATION OF INTERN
Notwithstanding anything in this Agreement to the contrary, Hospital may suspend the right of
Intern to access the Hospital facilities if, in the sole judgment and discretion of Hospital, the
conduct or attitude of the Intern threatens the health, safety, or welfare of any patient at Hospital
or the confidentiality of any information relating to a patient. This action shall be taken by
Hospital only on a temporary basis until Hospital has consulted with DPH. The consultation
shall include an attempt to resolve the suspension, but the final decision regarding the Intern’s
continued participation in the Intern Observer experience at Hospital is vested in Hospital.
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6. GENERAL PROVISIONS
6.1 Compliance with Laws and Regulations. Hospital shall maintain its license as a
general acute care facility and comply with or exceed all applicable laws, regulations, the Joint
Commission standards.
6.2 Non-Discrimination. The parties understand and agree that neither party will
discriminate against any person because of race, color, religion, sex, marital status, national
origin, age, physical handicap, medical condition or financial status as provided by law.
6.3 Interruption of Service. Either party shall be excused from any delay or failure
in performance hereunder caused by reason of any occurrence or contingency beyond its
reasonable control, including, but not limited to, acts of God, acts of war, fire, insurrection, labor
disputes, riots, earthquakes, or other acts of nature. The obligations and rights of the party so
excused shall be extended on a day-to-day basis for the time period equal to the period of such
excusable interruption. In the event the interruption of the excused party's obligations continues
for period in excess of thirty (30) days, the other party shall have the right to terminate this
Agreement upon ten (10) days' prior written notice to the excused party.
6.4 Assignment. Neither party shall assign their rights, duties, or obligations under
this Agreement, either in whole or in part, without the prior written consent of the other.
6.5 Severability. If any provision of this Agreement is held to be illegal, invalid, or
unenforceable under present or future laws effective during the term hereof, such provision shall
be fully severable. This Agreement shall be construed and enforced as if such illegal, invalid, or
unenforceable provision had never been a part of the Agreement, and the remaining provisions
shall remain in full force and effect unaffected by such severance, provided that the severed
provision(s) are not material to the overall purpose and operation of this Agreement.
6.6 Waiver. Waiver by either party of any breach of any provision of this Agreement
or warranty of representation herein set forth shall not be construed as a waiver of any
subsequent breach of the same or any other provision. The failure to exercise any right
hereunder shall not operate as a waiver of such right. All rights and remedies provided for herein
are cumulative.
6.7 Modification and Amendments. This Agreement may be amended or modified
at any time by mutual written consent of the authorized representatives of both parties.
6.8 No Third Party Beneficiaries. This Agreement is entered into by and between
the parties for their benefit. This Agreement is not intended to create and does not create any
right or interest in any Resident, patient, or other third party.
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6.9 Entire Agreement. This Agreement and Exhibits attached hereto contains all the
terms and conditions agreed upon by the parties regarding the subject matter of this Agreement
and supersedes any prior agreements, oral or written, and all other communications between the
parties relating to such subject matter.
6.10 Governing Law. This Agreement shall be governed by and construed under the
laws of the State of Arizona without regard to those laws relating to conflict of laws, and is
subject to the provisions of A.R.S. § 38-511.
6.11 Counterparts. This Agreement may be executed in one or more counterparts,
each of which shall be deemed to be an original, but all of which together shall constitute one
and the same instrument.
6.12 Notices. All notices required under this Agreement shall be deemed to have been
fully given when made in writing and deposited in the United States mail, postage prepaid,
certified mail, return receipt requested, and addressed as follows:
To Hospital: St. Joseph’s Hospital and Medical Center
350 West Thomas Road
Phoenix, AZ 85013
Attn: Hospital President/CEO
With a copy to: Dignity Health
Legal Department
3030 N. Central Avenue, Suite 1002
Phoenix, AZ 85012
Attn: Vice President and Associate General Counsel
To DPH: 4041 North Central Avenue - Ste. 1400
Phoenix, Arizona 85012
6.13 Insurance.
(a) Each party shall have in effect at all times during the term of this Agreement
insurance or comparable self-insurance which is adequate to protect the other party, its officers and
employees, participants and equipment against such losses as are set forth below.
(b) Hospital shall provide DPH, upon request, with a current Certificate of
Insurance or a certified copy of the insurance policy naming Maricopa County as an additional
insured under Hospital’s commercial general liability and commercial automobile liability
insurance; or, if Hospital is self-insured, shall provide the DPH with current documentation of self-
insurance coverage by furnishing a letter indicating such.
(c) The following types and amounts of insurance are required as minimums:
1. Workers’ Compensation as required by Arizona law, and Employer’s
Liability Insurance of $1,000,000 each accident, $1,000,000 disease
and $1,000,000 disease policy limits.
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2. Unemployment Insurance as required by Arizona law.
3. Commercial general liability insurance with a minimum of
$1,000,000 each occurrence, $2,000,000 general aggregate and
$2,000,000 products/completed operations aggregate. The policy
shall include coverage for public liability, bodily injury, and property
damage, personal injury (including coverage for contractual and
employee acts) and blanket contractual.
4. Standard minimum deductible amounts are allowable. Any losses
applied against insurance deductibles are the sole responsibility of
Hospital.
5. Professional Liability Insurance with a minimum combined single
limit of $1,000,000 for each claim and $3,000,000 aggregate.
6. Commercial Automobile Liability Insurance with a combined single
limit of $1,000,000.
(d) Hospital will immediately inform the Dietetic Internship Program Director
of any cancellation of its insurance or any decrease in its lines of coverage at least thirty (30) days
before such action takes place.
6.14 Indemnity. Each party (as “indemnitor”) agrees to indemnify, defend, and hold
harmless the other party (as “indemnitee”) from and against any and all claims, losses, damages and
expenses (including reasonable attorney’s fees), hereinafter collectively referred to as “claims,”
arising out of the negligent acts, misconduct or omissions of the indemnitor, its agents, or
employees.
6.15 E-Verify.
COMPLIANCE REQUIREMENTS FOR A.R.S. § 41-4401, GOVERNMENT PROCUREMENT;
E-VERIFY REQUIREMENT
(a) Hospital warrants compliance with all federal immigration laws and
regulations relating to employees and warrants its compliance with A.R.S. § 23-214, Subsection A
(that subsection reads: “After December 31, 2007, every employer, after hiring an employee, shall
verify the employment eligibility of the employee through the E-Verify program and shall keep a
record of the verification for the duration of the employee’s employment or at least three years,
whichever is longer”).
(b) A breach of warranty regarding compliance with immigration laws and
regulations shall be deemed a material breach of this Agreement and Hospital may be subject to
penalties up to and including termination of the Agreement.
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(c) Failure to comply with a State audit process to randomly verify the
employment records of contractors and subcontractors shall be deemed a material breach of this
Agreement and Hospital may be subject to penalties up to and including termination of the
Agreement.
(d) The State of Arizona retains the legal right to inspect the papers of any
employee who works on this Agreement to ensure that the contractor or subcontractor is complying
with the warranty under Section 6.15(a).
(e) For questions about E-Verify, Hospital should visit the following web site:
http://www.uscis.gov/portal/site/uscis.
IN WITNESS, WHEREOF, intending to be legally bound, each party has caused this
Agreement to be signed by its duly authorized officer as of the final date of signature written below:
DIGNITY HEALTH, d/b/a ST. MARICOPA COUNTY, BY AND FOR
JOSEPH’S HOSPITAL AND ITS DEPARTMENT OF PUBLIC
MEDICAL CENTER, MERCY HEALTH
GILBERT MEDICAL CENTER and
CHANDLER REGIONAL MEDICAL
CENTER
By:
Senior VP of Operations and Chairman
President/CEO, Maricopa County Board of
Dignity Health Arizona Supervisors
Date: Date:
Approved as to Form: Attest:
Joseph A. Mislove, Esq.
Date: 8/7/2014
630176.doc Clerk of the Board Date
Dignity Health Legal Department -
Phoenix Office
Director, MCDPH Date
Approved as to Form Date
Deputy County Attorney
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[Intern must present an originally signed copy of this Exhibit A to Hospital upon commencement of the Intern
Observer experience at Hospital]
EXHIBIT A
INTERN OBSERVER
DECLARATION OF RESPONSIBILITIES
I, _______________________________, hereby state, represent and agree that:
1. I am over eighteen (18) years old.
2. I am a registered student in the Maricopa County Health Department’s Public Health
Dietitian program (“DPH”), and in order to gain experience, I am participating, of my own
accord, in an Intern Observer experience (“Intern”) at Hospital.
3. I agree that I am or will be current on health requirements for hospital-based clinicians in
Arizona, including immunization from measles, mumps, rubella and varicella and TB
testing prior to participation in the Intern Observer experience. I shall provide
documentation of compliance with this requirement to Hospital upon request.
4. I agree to conform to all applicable Hospital policies, procedures, and regulations, and such
other requirements and restrictions as may be mutually specified and agreed upon by
Hospital Staff Coordinator.
5. I understand and agree that I am responsible for my own transportation to and from
Hospital.
6. I understand and agree that I am responsible for my own medical care needs. I understand
that Hospital will provide access to emergency medical services or first aid should the need
arise while I am participating in the Intern Observer experience. However, I understand
and agree that I am fully responsible for all costs related to general medical or emergency
care, and that Hospital shall assume no cost or financial liability for providing such care.
7. I acknowledge that my experience at Hospital is purely educational and that I will not be
considered an employee of Hospital, nor shall I receive compensation from Hospital. I
further acknowledge that I am neither eligible for nor entitled to workers’ compensation
benefits under Hospital’s coverage based upon my participation in the Intern Observer
experience. I further acknowledge that I will not be provided any benefit plans, health
insurance coverage, or medical care based upon my participation in this Intern Observer
experience.
8. I understand that Hospital may suspend my right to participate in the Intern Observer
experience if, in its sole judgment and discretion, my conduct or attitude threatens the
health, safety or welfare of any patients, invitees, or employees at Hospital or the
confidentiality of any information relating to such persons, either as individuals or
collectively. I further understand that this action shall be taken by Hospital only on a
temporary basis until after consultation with me. The consultation shall include an attempt
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to resolve the suspension, but the final decision regarding my continued participation in the
Intern Observer experience at Hospital is vested in Hospital.
9. I agree that I shall not discriminate against any person because of race, color, religion, sex,
marital status, national origin, age, physical handicap, or medical condition.
10. I further understand that Hospital has the right to suspend use of its facilities in connection
with this Intern Observer experience should Hospital’s facilities be partially damaged or
destroyed and such damage is sufficient to make the facilities unsafe or unusable for their
purposes.
11. I recognize that medical records, patient care information, personnel information, reports to
regulatory agencies, conversations between or among any healthcare professionals may be
considered privileged and should be treated with utmost confidentiality. I further
understand that if it is determined that a breach in confidentiality has occurred as a result of
my actions, I can be held liable for damages that result from such a breach.
I have read the foregoing. I understand and agree to the terms set forth above. I recognize that
as consideration for agreeing to the said terms, Hospital will permit me to participate in the
Intern Observer experience at Hospital.
____________________________________
Intern Observer Signature Date Typed Name of Intern Observer
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[Intern must present an originally signed copy of this Exhibit B to Hospital upon commencement of the Intern
Observer experience at Hospital]
EXHIBIT B
INTERN OBSERVER STATEMENT OF CONFIDENTIALITY
The undersigned recognizes that in the course of participating in an Intern Observer educational
experience at St. Joseph’s Hospital and Medical Center, Mercy Gilbert Medical Center
and/or Chandler Regional Medical Center (“Hospital”), the undersigned may inadvertently be
afforded access to information subject to state and federal confidentiality and privacy laws. The
undersigned further recognizes that in consideration of the opportunity to participate in the Intern
Observer experience certain confidentiality obligations will be required as more specifically
defined herein.
Statement of Policy:
It is the legal and ethical responsibility of all Hospital observers participating in educational
experiences to use personal and confidential patient, employee and Hospital business information
(referred to here collectively as “confidential information”) in accordance with the law and the
Hospital’s policies and procedures, and to preserve and protect the privacy rights of the subject
of the information as they perform their educational activities at the Hospital.
Laws controlling the privacy of, access to and the maintenance of confidential information
include, but are not limited to, the federal Health Insurance Portability and Accountability Act of
1996 (“HIPAA”) and the Arizona Medical Records Act. These and other laws apply whether the
information is held in electronic or any other form, and whether the information is used or
disclosed orally or in writing.
Confidential information includes information that identifies or describes an individual and the
disclosure of which would constitute an unwarranted invasion of personal privacy. Examples of
confidential employee and Hospital business information include home address and telephone
number; medical information; birth date; citizenship; social security number;
spouse/partner/relative’s names; income tax withholding data and performance evaluations and
proprietary; trade secret information.
The term “medical information” includes: medical and psychiatric records, including paper
printouts, photos, videotapes, diagnostic and therapeutic reports, x-rays, scans, laboratory and
pathology samples; patient business records, such as bills for service or insurance information
whether stored externally or on Hospital’s campus; electronically stored or transmitted patient
information; visual observation of patients receiving medical care or accessing services; verbal
information provided by or about a patient; peer review/risk management information and
activities; or other information the disclosure of which would constitute an unwarranted invasion
of privacy.
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Acknowledgement of Responsibility
I understand and acknowledge that:
It is my legal and ethical responsibility to preserve and protect the privacy, confidentiality and
security of all medical records, proprietary and other confidential information relating to
Hospital, its patients, activities and affiliates, in accordance with the law and Hospital’s policies
and procedures.
I agree to access, use or disclose confidential information only in the performance of my
educational activities, where required by or permitted by law, and only to persons who have the
right to receive that information. When using or disclosing confidential information, I will use
or disclose only within the Hospital premises and as related to and/or required by my educational
observer experience. I understand and agree that I am prohibited from taking individually
identifiable patient information off Hospital’s premises for any reason whatsoever. I further
understand and agree that I will not use or disclose any individually identifiable patient
information in relation to any of my academic work related to the observer experience.
I agree to discuss confidential information only in the workplace and for Hospital-related
purposes. I will not knowingly discuss confidential information within the hearing of other
persons who do not have the right to receive the information. I agree to protect the
confidentiality of any medical, proprietary or other confidential information, which is
incidentally disclosed to me in the course of my relationship with Hospital.
I understand that if given access to the Hospital network, my use of Hospital electronic
information systems is subject to audit in accordance with Hospital policy.
I agree that if given access to the Hospital network, I will not share my Login or User ID and/or
password with anyone and that any access to Hospital electronic information systems made using
my Login or User ID and password is my responsibility. If I believe someone else has used my
Login or User ID and /or password, I will immediately report the use to Information Technology
Services and request a new password.
I understand that violation of any of the Hospital’s policies and procedures related to confidential
information or of any state or federal laws or regulations governing a patient’s right to privacy
may subject me to legal and/or disciplinary action up to and including immediate termination of
my Intern Observer experience.
I understand that I may be personally liable for harm resulting from my breach of this Policy and
that I may also be held criminally liable under the HIPAA privacy regulations for an intentional
and/or malicious release of protected health information.
By signing this Oath of Confidentiality, the undersigned, Intern, certifies and agrees that:
1. He or she has received, read and understands this Statement of Confidentiality;
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2. He or she shall observe and be bound by the provisions of the Statement of
Confidentiality at all times while participating as a Intern Observer; and
3. He or she will seek advice, as necessary, from applicable members of Hospital
administration concerning appropriate actions he may need to take to comply with the
Statement of Confidentiality.
___________________________________ _______________________
Signature Date
Intern
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EXHIBIT C
OBSERVATION OBJECTIVES
Dietetic Internship Curriculum and Evaluation
Rotation: Dignity Health Arizona Weeks of Supervised
Practice: 11 weeks
Practice Hours: 400 Didactic Hours: 0
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
 There will be no hands-on care provided to patients
 Interns will be in the presence of a preceptor (Dignity Health staff Dietitian) in the
facility’s care areas
 Interns will not document in Electronic Medical Record, but may use their own forms
which become a part of the medical record
 Interns notes must be co-signed by the Dignity Health staff Dietitian
General Activities/Staff Experience
DI Competencies Planned Learning Experience Rating
DI 1.2 Apply evidence-based guidelines, ▪ Research, write and present journal □ □
systematic reviews and scientific literature article abstracts on a minimum of 3 4 3 2
(such as the ADA Evidence Analysis areas of Medical Nutrition Therapy. □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
DI 1.1 Select appropriate indicators and ▪ Research, develop, present and evaluate □ □
measure achievement of clinical, one in-service presentation for trayline. 4 3 2
programmatic, quality, productivity, □ 1 □
economic or other outcomes.
DI 1.2 Apply evidence-based guidelines,
systematic reviews and scientific literature
(such as the ADA Evidence Analysis
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
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DI Competencies Planned Learning Experience Rating
dietetics practice.
DI 2.3 Design, implement and evaluate
presentations considering life experiences,
cultural diversity and educational
background of the target audience.
DI 2.4 Use effective education and
counseling skills to facilitate behavior
change.
DI 4.5 Conduct clinical and customer service
quality management activities.
DI 1.2 Apply evidence-based guidelines, ▪ Develop case study for minimum of □ □
systematic reviews and scientific literature three patients; must orally present at 4 3 2
(such as the ADA Evidence Analysis least one case study to staff. □ 1 □
Library, Cochrane Database of Systemic o Areas at discretion of intern,
Reviews and the U.S. Department of Health unless supervising RD states
and Human Services, Agency for Healthcare otherwise.
Research and Quality, National Guideline o Guidelines for case studies are
Clearinghouse Web sites) in the nutrition in DI handbook.
care process and model and other areas of
dietetics practice.
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 4.5 Conduct clinical and customer service ▪ Develop and implement a quality □ □
quality management activities. improvement (QI) measure and report 4 3 2
QI results with Supervising RD. □ 1 □
DI 3.1.a. Assess the nutritional status of ▪ Prioritize census and manage patient □ □
individuals, groups and populations in a care based on clinical priorities. 4 3 2
variety of settings where nutrition care is or ▪ Review and evaluate processes used to □ 1 □
can be delivered. screen and assess patients.
▪ Review results of screening, assessing, 4 □ 3 □ 2
and documentation procedures with
managing RD. □ 1 □
4 □ 3 □ 2
□ 1 □
DI 4.5 Conduct clinical and customer service ▪ Supervise a Trayline Audit. □ □
quality management activities. 4 3 2
□ 1 □
DI 3.1.a. Assess the nutritional status of ▪ Supervise the daily operation of a unit □ □
individuals, groups and populations in a during two weeks of staff relief. 4 3 2
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DI Competencies Planned Learning Experience Rating
variety of settings where nutrition care is or □ □
can be delivered. 1
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
CO1 Manage nutrition care for population ▪ Facilitate nutrition classes for adults □ □
groups across the lifespan (cardiac, COPD, wt. Control, DM, etc.) 4 3 2
□ 1 □
Other Competencies Planned Learning Experience Check if
Completed
Background ▪ Orientation and tour of facility. □
Education ▪ Spend one day with Dietetic □
Technicians.
Education ▪ Spend one day with the Patient Care □
Food Service Manager.
Education ▪ Spend time with the managing RD. □
Evaluation ▪ Turn in all written/oral assignments □
Evaluation ▪ Review evaluations with preceptor and □
formulate future goals for professional
development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Comments:
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Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Diabetes / Cardiology Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Cardiology/Hypertension. 4 3
o Diabetes. 2 □ 1 □
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3
(such as the ADA Evidence Analysis 2 □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for
Healthcare Research and Quality, National
Guideline Clearinghouse Web sites) in the
nutrition care process and model and other
areas of dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
DI 1.4 Evaluate emerging research for ▪ Review available Patient Education □ □
application in dietetics practice. Material. 4 3 2
□ 1 □
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from site – 4 3
nutrition diagnosis, formulating a nutrition minimum of 2 per area, then as needed. 2 □ 1 □
prescription, establishing goals and
selecting and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel a minimum □ □
federal regulations and state statutes and of two patients for each in DM and Cardiac 4 3
rules, as applicable and in accordance with – have preceptor complete and sign 2 □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
of Dietetics Practice Framework, Standards Form (form should be completed until the
of Professional Performance and Code of intern receives a passing score of 32 or
Ethics for the Profession of Dietetics. above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support
personnel considering the needs of the
patient/client or situation, the ability of
support personnel, jurisdictional law,
practice guidelines and policies within the
facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
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DI Competencies Planned Learning Experience Rating
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and
selecting and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes.
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
activities to DTRs and /or support intervention for patient. Chart in patient’s 4 3
personnel considering the needs of the medical record using hospital standards – 2 □ 1 □
patient/client or situation, the ability of minimum of 3 per week.
support personnel, jurisdictional law,
practice guidelines and policies within the
facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and
selecting and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker, cardiac □ □
activities to DTRs and /or support educator, or other allied health professional 4 3
personnel considering the needs of the as needed. 2 □ 1 □
patient/client or situation, the ability of
support personnel, jurisdictional law,
practice guidelines and policies within the
facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative
relationships with internal and external
stakeholders, including patients, clients,
care givers, physicians, nurses and other
health professionals, administrative and
support personnel to facilitate individual
and organizational goals.
DI 2.3 Design, implement and evaluate ▪ Teach DM or Cardiology class, as □ □
presentations considering life experiences, available. 4 3
cultural diversity and educational 2 □ 1 □
background of the target audience.
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DI Competencies Planned Learning Experience Rating
DI 2.4 Use effective education and
counseling skills to facilitate behavior
change.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient per
area (inpatient and outpatient settings, if
available)
Education ▪ Review activities with Supervising RD □
on a daily basis.
Education ▪ Observe/attend core DM or Cardiac □
class, as available.
Evaluation ▪ Turn in all written/oral assignments. □
Evaluation ▪ Review evaluations with preceptor and □
formulate future goals for professional
development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Neurology Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Neurology Study Guide 4 3 2
□ 1 □
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3 2
(such as the ADA Evidence Analysis □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
dietetics practice.
DI 1.4 Evaluate emerging research for
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DI Competencies Planned Learning Experience Rating
application in dietetics practice.
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from 4 3 2
nutrition diagnosis, formulating a nutrition site – minimum of 2 per area, then as □ 1 □
prescription, establishing goals and selecting needed.
and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel a □ □
federal regulations and state statutes and minimum of three patients/week – have 4 3 2
rules, as applicable and in accordance with preceptor complete and sign □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
of Dietetics Practice Framework, Standards Form (form should be completed until
of Professional Performance and Code of the intern receives a passing score of 32
Ethics for the Profession of Dietetics. or above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes.
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
activities to DTRs and /or support personnel intervention for patient. Chart in 4 3 2
considering the needs of the patient/client or patient’s medical record using hospital □ 1 □
situation, the ability of support personnel, standards – minimum of 3 per week.
jurisdictional law, practice guidelines and
policies within the facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
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DI Competencies Planned Learning Experience Rating
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker or other □ □
activities to DTRs and /or support personnel allied health professional as needed. 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 2.6 Assign appropriate patient care ▪ Spend a day with the speech therapist. □ □
activities to DTRs and /or support personnel 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 2.3 Design, implement and evaluate ▪ Teach the Fiber Class to the spinal □ □
presentations considering life experiences, patients, if available. 4 3 2
cultural diversity and educational □ 1 □
background of the target audience.
DI 2.4 Use effective education and
counseling skills to facilitate behavior
change.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient per
area.
Evaluation ▪ Turn in all written/oral assignments. □
Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
professional development.
630176.doc Page 20 [140455]

Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Outpatient Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Outpatient / Obesity Study 4 3 2
Guide. □ 1 □
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3 2
(such as the ADA Evidence Analysis □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
DI 1.4 Evaluate emerging research for ▪ Review available Outpatient study □ □
application in dietetics practice. materials, as needed for application in 4 3 2
rotation. □ 1 □
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from 4 3 2
nutrition diagnosis, formulating a nutrition site – minimum of 3, then as needed. □ 1 □
prescription, establishing goals and selecting
and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel a □ □
federal regulations and state statutes and minimum of three patients – have 4 3 2
rules, as applicable and in accordance with preceptor complete and sign □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
of Dietetics Practice Framework, Standards Form (form should be completed until
of Professional Performance and Code of the intern receives a passing score of 32
Ethics for the Profession of Dietetics. or above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
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DI Competencies Planned Learning Experience Rating
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes.
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
activities to DTRs and /or support personnel intervention for patient. Chart in 4 3 2
considering the needs of the patient/client or patient’s medical record using site’s □ 1 □
situation, the ability of support personnel, standards – minimum of 3 per week.
jurisdictional law, practice guidelines and
policies within the facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker or other □ □
activities to DTRs and /or support personnel allied health professional as needed. 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 4.12 Participate in coding and billing of ▪ Participate in experience with □ □
dietetics/nutrition services to obtain coding/billing of dietetics/nutrition 4 3 2
630176.doc Page 22 [140455]

DI Competencies Planned Learning Experience Rating
reimbursement for services from public or services to obtain reimbursement for □ □
private insurers. services. 1
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview and counsel a □
minimum of one patient.
Education ▪ Review interpretation of labs with RD. □
Education ▪ Review outpatient counseling skills, □
goal setting and follow-up with RD.
Education ▪ Attend available classes and medical □
meetings.
Evaluation ▪ Turn in all written/oral assignments. □
Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
professional development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Metabolic Support Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Nutrition Support Study Guide. 4 3 2
□ 1 □
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3 2
(such as the ADA Evidence Analysis □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
630176.doc Page 23 [140455]

DI Competencies Planned Learning Experience Rating
DI 3.1.a. Assess the nutritional status of ▪ Observe and perform nutrition risk □ □
individuals, groups and populations in a screening in SICU as cases occur. 4 3 2
variety of settings where nutrition care is or □ 1 □
can be delivered.
DI 1.1 Select appropriate indicators and ▪ On assigned days: □ □
measure achievement of clinical, o For 1-2 patients each day, 4 3 2
programmatic, quality, productivity, complete nutritional assessment □ 1 □
economic or other outcomes. and care plan.
DI 2.1 Practice in compliance with current o Review pathophysiology of Dx
federal regulations and state statutes and and medical Hx.
rules, as applicable and in accordance with o Monitor and follow-up with
accreditation standards and the ADA Scope patients as appropriate.
of Dietetics Practice Framework, Standards o Develop and implement
of Professional Performance and Code of transitional feeding plans.
Ethics for the Profession of Dietetics. o Confer with other disciplines as
DI 2.4 Use effective education and needed (social services,
counseling skills to facilitate behavior respiratory therapy, speech
change. therapy, etc.).
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.8 Demonstrate initiative by proactively
developing solutions to problems.
DI 2.9 Apply leadership principles
effectively to achieve desired outcomes.
DI 3.1.c Plan and implement nutrition ▪ Review follow-up care for patients □ □
interventions to include prioritizing the transferred to telemetry, TIMC and 4 3 2
nutrition diagnosis, formulating a nutrition Rehab. □ 1 □
prescription, establishing goals and selecting
630176.doc Page 24 [140455]

DI Competencies Planned Learning Experience Rating
and managing intervention.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.4 Use effective education and ▪ Develop transitional feedings; □ □
counseling skills to facilitate behavior coordinate with Home Health Care or 4 3 2
change. caregiver. □ 1 □
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
Other Competencies Planned Learning Experience Check if
Completed
Background ▪ Orientation to unit. □
Education ▪ Review Standards of TPN protocol, □
enteral formulary and enteral feeding
tubes.
Education ▪ Review procedures for ordering and □
dispensing tube feedings and
supplements.
Education ▪ Observe RD assess and consult □
minimum of 3 patients.
Evaluation ▪ Turn in all written/oral assignments. □
▪ Review evaluations with preceptor and □
formulate future goals for professional
development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Oncology Rotation
630176.doc Page 25 [140455]

DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Oncology Study Guide. 4 3 2
□ 1 □
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3 2
(such as the ADA Evidence Analysis □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
DI 3.1.d Monitor and evaluate problems, ▪ Review Cardex information on □ □
etiologies, signs, symptoms and the impact Med/Surg unit, note therapeutic diets 4 3 2
of interventions on the nutrition diagnosis. and review pathophysiology. □ 1 □
DI 3.1.a. Assess the nutritional status of ▪ Screen patients on Med/Surg unit to □ □
individuals, groups and populations in a determine pt. nutritional risk. 4 3 2
variety of settings where nutrition care is or □ 1 □
can be delivered.
DI 2.1 Practice in compliance with current ▪ For minimum of two high risk pts not □ □
federal regulations and state statutes and receiving nutritional support (one 4 3 2
rules, as applicable and in accordance with inpatient and one radiation outpatient): □ 1 □
accreditation standards and the ADA Scope o Review charts – interpret labs
of Dietetics Practice Framework, Standards and review pathophysiology.
of Professional Performance and Code of o Interview pt. – have preceptor
Ethics for the Profession of Dietetics. review and sign Interviewing
DI 2.6 Assign appropriate patient care and Counseling Evaluation
activities to DTRs and /or support personnel Form.
considering the needs of the patient/client or o Evaluate and compare current
situation, the ability of support personnel, diet orders and appropriate
jurisdictional law, practice guidelines and interventions with RD.
policies within the facility. o Discuss pts educational
DI 2.7 Refer clients and patients to other requirements with RD. 4 □ 3 □ 2
professionals and services when needs are o Counsel pt. – have preceptor
beyond individual scope of practice. review and sign Interviewing □ 1 □
DI 3.1.a. Assess the nutritional status of and Counseling Evaluation
individuals, groups and populations in a Form.
variety of settings where nutrition care is or o Document findings in medical
can be delivered. charts.
DI 3.1.c Plan and implement nutrition ▪ For minimum of two high risk pts
interventions to include prioritizing the receiving TPN/Enteral Nutrition:
nutrition diagnosis, formulating a nutrition o Review charts – emphasize
prescription, establishing goals and selecting TPN/Enteral formulas and
and managing intervention. macronutrient adjustments.
DI 3.1.d Monitor and evaluate problems, o Interview pt. – have preceptor
etiologies, signs, symptoms and the impact review and sign Interviewing
of interventions on the nutrition diagnosis. and Counseling Evaluation
DI 3.5 Deliver respectful, science-based Form.
answer to consumer questions concerning o Calculate protein, energy and
emerging trends. fluid needs, and adjust diet to
630176.doc Page 26 [140455]

DI Competencies Planned Learning Experience Rating
meet needs within therapeutic
guidelines.
o Interpret labs and review
pathophysiology.
o Evaluate and compare current
diet orders and appropriate
interventions with RD.
o Discuss pts educational
requirements with RD.
o Counsel pt. – have preceptor
review and sign Interviewing
and Counseling Evaluation
Form.
o Document findings in medical
charts.
o Develop transitional feeding
plan.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker or other □ □
activities to DTRs and /or support personnel allied health professionals, as needed. 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient.
Education ▪ Discuss role of RD in community □
oncology services, e.g. Hospice,
palliative care, prevention, etc.
Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
professional development.
Supervising RD Signature:
Date:
Intern Name:
Date:
630176.doc Page 27 [140455]

Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Internal Medicine Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Internal Medicine and 4 3 2
Transplant Study Guide □ 1 □
DI 1.4 Evaluate emerging research for ▪ Review educational materials available □ □
application in dietetics practice. for each disease state. 4 3 2
□ 1 □
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from 4 3 2
nutrition diagnosis, formulating a nutrition site. □ 1 □
prescription, establishing goals and selecting
and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel patient in □ □
federal regulations and state statutes and the following areas: renal, GI and liver 4 3 2
rules, as applicable and in accordance with – have preceptor complete and sign □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
of Dietetics Practice Framework, Standards Form (form should be completed until
of Professional Performance and Code of the intern receives a passing score of 32
Ethics for the Profession of Dietetics. or above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
4 3 2
630176.doc Page 28 [140455]

DI Competencies Planned Learning Experience Rating
activities to DTRs and /or support personnel intervention for patient. Chart in □ □
considering the needs of the patient/client or patient’s medical record using hospital 1
situation, the ability of support personnel, standards.
jurisdictional law, practice guidelines and
policies within the facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker, physical □ □
activities to DTRs and /or support personnel therapist or other allied health 4 3 2
considering the needs of the patient/client or professionals as needed. □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 3.4 Develop and deliver products, ▪ Prepare and conduct a taste test of □ □
programs and services that promote supplements/food/beverage products to 4 3 2
consumer health, wellness and lifestyle be utilized for inpatient or outpatient □ 1 □
management merging consumer desire for care.
taste, convenience and economy with
nutrition, food safety and health messages
and interventions.
DI 3.6 Coordinate procurement, production,
distribution and service of goods and
services.
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient per
area; inform supervising RD if a
disease state has not been seen.
Education ▪ Observe PEG placement or duotube □
insertion (optional).
Evaluation ▪ Turn in all written/oral assignments. □
630176.doc Page 29 [140455]

Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
professional development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Pediatric Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Pediatric Study Guide. 4 3 2
□ 1 □
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from 4 3 2
nutrition diagnosis, formulating a nutrition site – minimum of 2, then as needed. □ 1 □
prescription, establishing goals and selecting
and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel a □ □
federal regulations and state statutes and minimum of 3 patients per week – have 4 3 2
rules, as applicable and in accordance with preceptor complete and sign □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
of Dietetics Practice Framework, Standards Form (form should be completed until
of Professional Performance and Code of the intern receives a passing score of 32
Ethics for the Profession of Dietetics. or above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
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DI Competencies Planned Learning Experience Rating
prescription, establishing goals and selecting
and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes.
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
activities to DTRs and /or support personnel intervention for patient. Chart in 4 3 2
considering the needs of the patient/client or patient’s medical record using site’s □ 1 □
situation, the ability of support personnel, standards – minimum of 3 per week.
jurisdictional law, practice guidelines and
policies within the facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker or other □ □
activities to DTRs and /or support personnel allied health professionals as needed. 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient per
area.
Education ▪ Review activities with Supervising □
RD on a daily basis.
Education ▪ Observe dietitians in Children’s □
Rehabilitation Services Clinic and
feeding clinic.
630176.doc Page 31 [140455]

Education ▪ Spend time observing the NNICU unit □
and RD.
Evaluation ▪ Turn in all written/oral assignments. □
Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
professional development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Diabetes / Cardiology Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Cardiology/Hypertension. 4 3
o Diabetes. 2 □ 1 □
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3
(such as the ADA Evidence Analysis 2 □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for
Healthcare Research and Quality, National
Guideline Clearinghouse Web sites) in the
nutrition care process and model and other
areas of dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
DI 1.4 Evaluate emerging research for ▪ Review available Patient Education □ □
application in dietetics practice. Material. 4 3 2
□ 1 □
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from site – 4 3
nutrition diagnosis, formulating a nutrition minimum of 2 per area, then as needed. 2 □ 1 □
prescription, establishing goals and
selecting and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel a minimum □ □
federal regulations and state statutes and of two patients for each in DM and Cardiac 4 3
rules, as applicable and in accordance with – have preceptor complete and sign 2 □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
630176.doc Page 32 [140455]

DI Competencies Planned Learning Experience Rating
of Dietetics Practice Framework, Standards Form (form should be completed until the
of Professional Performance and Code of intern receives a passing score of 32 or
Ethics for the Profession of Dietetics. above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support
personnel considering the needs of the
patient/client or situation, the ability of
support personnel, jurisdictional law,
practice guidelines and policies within the
facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and
selecting and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes.
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
activities to DTRs and /or support intervention for patient. Chart in patient’s 4 3
personnel considering the needs of the medical record using hospital standards – 2 □ 1 □
patient/client or situation, the ability of minimum of 3 per week.
support personnel, jurisdictional law,
practice guidelines and policies within the
facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and
selecting and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker, cardiac □ □
activities to DTRs and /or support educator, or other allied health professional 4 3
personnel considering the needs of the as needed. 2 □ 1 □
patient/client or situation, the ability of
support personnel, jurisdictional law,
practice guidelines and policies within the
facility.
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DI Competencies Planned Learning Experience Rating
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative
relationships with internal and external
stakeholders, including patients, clients,
care givers, physicians, nurses and other
health professionals, administrative and
support personnel to facilitate individual
and organizational goals.
DI 2.3 Design, implement and evaluate ▪ Teach DM or Cardiology class, as □ □
presentations considering life experiences, available. 4 3
cultural diversity and educational 2 □ 1 □
background of the target audience.
DI 2.4 Use effective education and
counseling skills to facilitate behavior
change.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient per
area (inpatient and outpatient settings, if
available)
Education ▪ Review activities with Supervising RD □
on a daily basis.
Education ▪ Observe/attend core DM or Cardiac □
class, as available.
Evaluation ▪ Turn in all written/oral assignments. □
Evaluation ▪ Review evaluations with preceptor and □
formulate future goals for professional
development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
630176.doc Page 34 [140455]

Neurology Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Neurology Study Guide 4 3 2
□ 1 □
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3 2
(such as the ADA Evidence Analysis □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from 4 3 2
nutrition diagnosis, formulating a nutrition site – minimum of 2 per area, then as □ 1 □
prescription, establishing goals and selecting needed.
and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel a □ □
federal regulations and state statutes and minimum of three patients/week – have 4 3 2
rules, as applicable and in accordance with preceptor complete and sign □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
of Dietetics Practice Framework, Standards Form (form should be completed until
of Professional Performance and Code of the intern receives a passing score of 32
Ethics for the Profession of Dietetics. or above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes.
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
activities to DTRs and /or support personnel intervention for patient. Chart in 4 3 2
630176.doc Page 35 [140455]

DI Competencies Planned Learning Experience Rating
considering the needs of the patient/client or patient’s medical record using hospital □ □
situation, the ability of support personnel, standards – minimum of 3 per week. 1
jurisdictional law, practice guidelines and
policies within the facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker or other □ □
activities to DTRs and /or support personnel allied health professional as needed. 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 2.6 Assign appropriate patient care ▪ Spend a day with the speech therapist. □ □
activities to DTRs and /or support personnel 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 2.3 Design, implement and evaluate ▪ Teach the Fiber Class to the spinal □ □
presentations considering life experiences, patients, if available. 4 3 2
cultural diversity and educational □ 1 □
background of the target audience.
DI 2.4 Use effective education and
counseling skills to facilitate behavior
change.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
630176.doc Page 36 [140455]

DI Competencies Planned Learning Experience Rating
emerging trends.
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient per
area.
Evaluation ▪ Turn in all written/oral assignments. □
Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
professional development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Outpatient Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Outpatient / Obesity Study 4 3 2
Guide. □ 1 □
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3 2
(such as the ADA Evidence Analysis □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
DI 1.4 Evaluate emerging research for ▪ Review available Outpatient study □ □
application in dietetics practice. materials, as needed for application in 4 3 2
rotation. □ 1 □
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from 4 3 2
nutrition diagnosis, formulating a nutrition site – minimum of 3, then as needed. □ 1 □
prescription, establishing goals and selecting
630176.doc Page 37 [140455]

DI Competencies Planned Learning Experience Rating
and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel a □ □
federal regulations and state statutes and minimum of three patients – have 4 3 2
rules, as applicable and in accordance with preceptor complete and sign □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
of Dietetics Practice Framework, Standards Form (form should be completed until
of Professional Performance and Code of the intern receives a passing score of 32
Ethics for the Profession of Dietetics. or above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes.
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
activities to DTRs and /or support personnel intervention for patient. Chart in 4 3 2
considering the needs of the patient/client or patient’s medical record using site’s □ 1 □
situation, the ability of support personnel, standards – minimum of 3 per week.
jurisdictional law, practice guidelines and
policies within the facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker or other □ □
activities to DTRs and /or support personnel allied health professional as needed. 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
630176.doc Page 38 [140455]

DI Competencies Planned Learning Experience Rating
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 4.12 Participate in coding and billing of ▪ Participate in experience with □ □
dietetics/nutrition services to obtain coding/billing of dietetics/nutrition 4 3 2
reimbursement for services from public or services to obtain reimbursement for □ 1 □
private insurers. services.
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview and counsel a □
minimum of one patient.
Education ▪ Review interpretation of labs with RD. □
Education ▪ Review outpatient counseling skills, □
goal setting and follow-up with RD.
Education ▪ Attend available classes and medical □
meetings.
Evaluation ▪ Turn in all written/oral assignments. □
Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
professional development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Metabolic Support Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
4 3 2
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DI Competencies Planned Learning Experience Rating
application in dietetics practice. o Nutrition Support Study Guide. □ □
1
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3 2
(such as the ADA Evidence Analysis □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
DI 3.1.a. Assess the nutritional status of ▪ Observe and perform nutrition risk □ □
individuals, groups and populations in a screening in SICU as cases occur. 4 3 2
variety of settings where nutrition care is or □ 1 □
can be delivered.
DI 1.1 Select appropriate indicators and ▪ On assigned days: □ □
measure achievement of clinical, o For 1-2 patients each day, 4 3 2
programmatic, quality, productivity, complete nutritional assessment □ 1 □
economic or other outcomes. and care plan.
DI 2.1 Practice in compliance with current o Review pathophysiology of Dx
federal regulations and state statutes and and medical Hx.
rules, as applicable and in accordance with o Monitor and follow-up with
accreditation standards and the ADA Scope patients as appropriate.
of Dietetics Practice Framework, Standards o Develop and implement
of Professional Performance and Code of transitional feeding plans.
Ethics for the Profession of Dietetics. o Confer with other disciplines as
DI 2.4 Use effective education and needed (social services,
counseling skills to facilitate behavior respiratory therapy, speech
change. therapy, etc.).
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
630176.doc Page 40 [140455]

DI Competencies Planned Learning Experience Rating
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.8 Demonstrate initiative by proactively
developing solutions to problems.
DI 2.9 Apply leadership principles
effectively to achieve desired outcomes.
DI 3.1.c Plan and implement nutrition ▪ Review follow-up care for patients □ □
interventions to include prioritizing the transferred to telemetry, TIMC and 4 3 2
nutrition diagnosis, formulating a nutrition Rehab. □ 1 □
prescription, establishing goals and selecting
and managing intervention.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.4 Use effective education and ▪ Develop transitional feedings; □ □
counseling skills to facilitate behavior coordinate with Home Health Care or 4 3 2
change. caregiver. □ 1 □
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
Other Competencies Planned Learning Experience Check if
Completed
Background ▪ Orientation to unit. □
Education ▪ Review Standards of TPN protocol, □
enteral formulary and enteral feeding
tubes.
Education ▪ Review procedures for ordering and □
dispensing tube feedings and
supplements.
Education ▪ Observe RD assess and consult □
minimum of 3 patients.
Evaluation ▪ Turn in all written/oral assignments. □
▪ Review evaluations with preceptor and □
formulate future goals for professional
development.
Supervising RD Signature:
Date:
Intern Name:
Date:
630176.doc Page 41 [140455]

Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Oncology Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Oncology Study Guide. 4 3 2
□ 1 □
DI 1.2 Apply evidence-based guidelines, ▪ Review journal articles, as necessary, for □ □
systematic reviews and scientific literature application in rotation. 4 3 2
(such as the ADA Evidence Analysis □ 1 □
Library, Cochrane Database of Systemic
Reviews and the U.S. Department of Health
and Human Services, Agency for Healthcare
Research and Quality, National Guideline
Clearinghouse Web sites) in the nutrition
care process and model and other areas of
dietetics practice.
DI 1.4 Evaluate emerging research for
application in dietetics practice.
DI 3.1.d Monitor and evaluate problems, ▪ Review Cardex information on □ □
etiologies, signs, symptoms and the impact Med/Surg unit, note therapeutic diets 4 3 2
of interventions on the nutrition diagnosis. and review pathophysiology. □ 1 □
DI 3.1.a. Assess the nutritional status of ▪ Screen patients on Med/Surg unit to □ □
individuals, groups and populations in a determine pt. nutritional risk. 4 3 2
variety of settings where nutrition care is or □ 1 □
can be delivered.
DI 2.1 Practice in compliance with current ▪ For minimum of two high risk pts not □ □
federal regulations and state statutes and receiving nutritional support (one 4 3 2
rules, as applicable and in accordance with inpatient and one radiation outpatient): □ 1 □
accreditation standards and the ADA Scope o Review charts – interpret labs
of Dietetics Practice Framework, Standards and review pathophysiology.
of Professional Performance and Code of o Interview pt. – have preceptor
Ethics for the Profession of Dietetics. review and sign Interviewing
DI 2.6 Assign appropriate patient care and Counseling Evaluation
activities to DTRs and /or support personnel Form.
considering the needs of the patient/client or o Evaluate and compare current
situation, the ability of support personnel, diet orders and appropriate
jurisdictional law, practice guidelines and interventions with RD.
policies within the facility. o Discuss pts educational
DI 2.7 Refer clients and patients to other requirements with RD. 4 □ 3 □ 2
professionals and services when needs are o Counsel pt. – have preceptor
beyond individual scope of practice. review and sign Interviewing □ 1 □
DI 3.1.a. Assess the nutritional status of and Counseling Evaluation
individuals, groups and populations in a Form.
variety of settings where nutrition care is or o Document findings in medical
can be delivered. charts.
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DI Competencies Planned Learning Experience Rating
DI 3.1.c Plan and implement nutrition ▪ For minimum of two high risk pts
interventions to include prioritizing the receiving TPN/Enteral Nutrition:
nutrition diagnosis, formulating a nutrition o Review charts – emphasize
prescription, establishing goals and selecting TPN/Enteral formulas and
and managing intervention. macronutrient adjustments.
DI 3.1.d Monitor and evaluate problems, o Interview pt. – have preceptor
etiologies, signs, symptoms and the impact review and sign Interviewing
of interventions on the nutrition diagnosis. and Counseling Evaluation
DI 3.5 Deliver respectful, science-based Form.
answer to consumer questions concerning o Calculate protein, energy and
emerging trends. fluid needs, and adjust diet to
meet needs within therapeutic
guidelines.
o Interpret labs and review
pathophysiology.
o Evaluate and compare current
diet orders and appropriate
interventions with RD.
o Discuss pts educational
requirements with RD.
o Counsel pt. – have preceptor
review and sign Interviewing
and Counseling Evaluation
Form.
o Document findings in medical
charts.
o Develop transitional feeding
plan.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker or other □ □
activities to DTRs and /or support personnel allied health professionals, as needed. 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient.
Education ▪ Discuss role of RD in community □
oncology services, e.g. Hospice,
palliative care, prevention, etc.
Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
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professional development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Internal Medicine Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Internal Medicine and 4 3 2
Transplant Study Guide □ 1 □
DI 1.4 Evaluate emerging research for ▪ Review educational materials available □ □
application in dietetics practice. for each disease state. 4 3 2
□ 1 □
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from 4 3 2
nutrition diagnosis, formulating a nutrition site. □ 1 □
prescription, establishing goals and selecting
and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel patient in □ □
federal regulations and state statutes and the following areas: renal, GI and liver 4 3 2
rules, as applicable and in accordance with – have preceptor complete and sign □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
of Dietetics Practice Framework, Standards Form (form should be completed until
of Professional Performance and Code of the intern receives a passing score of 32
Ethics for the Profession of Dietetics. or above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
630176.doc Page 44 [140455]

DI Competencies Planned Learning Experience Rating
prescription, establishing goals and selecting
and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
activities to DTRs and /or support personnel intervention for patient. Chart in 4 3 2
considering the needs of the patient/client or patient’s medical record using hospital □ 1 □
situation, the ability of support personnel, standards.
jurisdictional law, practice guidelines and
policies within the facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker, physical □ □
activities to DTRs and /or support personnel therapist or other allied health 4 3 2
considering the needs of the patient/client or professionals as needed. □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
DI 3.4 Develop and deliver products, ▪ Prepare and conduct a taste test of □ □
programs and services that promote supplements/food/beverage products to 4 3 2
consumer health, wellness and lifestyle be utilized for inpatient or outpatient □ 1 □
management merging consumer desire for care.
taste, convenience and economy with
nutrition, food safety and health messages
and interventions.
DI 3.6 Coordinate procurement, production,
distribution and service of goods and
services.
630176.doc Page 45 [140455]

Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient per
area; inform supervising RD if a
disease state has not been seen.
Education ▪ Observe PEG placement or duotube □
insertion (optional).
Evaluation ▪ Turn in all written/oral assignments. □
Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
professional development.
Supervising RD Signature:
Date:
Intern Name:
Date:
Please evaluate intern’s demonstration of each ADA competency as:
4: Exceeds
3: Meets
2*: Marginal
1*: Did Not Meet Competency
Note*: A score of 1 or 2 means that the intern will not get any credit for this competency.
Pediatric Rotation
DI Competencies Planned Learning Experience Rating
DI 1.4 Evaluate emerging research for ▪ Complete the following study guide(s): □ □
application in dietetics practice. o Pediatric Study Guide. 4 3 2
□ 1 □
DI 3.1.c Plan and implement nutrition ▪ Obtain patient’s background information □ □
interventions to include prioritizing the using nutrition assessment form from 4 3 2
nutrition diagnosis, formulating a nutrition site – minimum of 2, then as needed. □ 1 □
prescription, establishing goals and selecting
and managing intervention.
DI 2.1 Practice in compliance with current ▪ Interview, assess and counsel a □ □
federal regulations and state statutes and minimum of 3 patients per week – have 4 3 2
rules, as applicable and in accordance with preceptor complete and sign □ 1 □
accreditation standards and the ADA Scope Interviewing and Counseling Evaluation
of Dietetics Practice Framework, Standards Form (form should be completed until
of Professional Performance and Code of the intern receives a passing score of 32
Ethics for the Profession of Dietetics. or above).
DI 2.6 Assign appropriate patient care
activities to DTRs and /or support personnel
considering the needs of the patient/client or
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
630176.doc Page 46 [140455]

DI Competencies Planned Learning Experience Rating
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing intervention.
DI 3.5 Deliver respectful, science-based
answer to consumer questions concerning
emerging trends.
DI 4.3 Apply systems theory and a process
approach to make decisions and maximize
outcomes.
DI 2.6 Assign appropriate patient care ▪ Assess, plan and implement nutrition □ □
activities to DTRs and /or support personnel intervention for patient. Chart in 4 3 2
considering the needs of the patient/client or patient’s medical record using site’s □ 1 □
situation, the ability of support personnel, standards – minimum of 3 per week.
jurisdictional law, practice guidelines and
policies within the facility.
DI 3.1.a. Assess the nutritional status of
individuals, groups and populations in a
variety of settings where nutrition care is or
can be delivered.
DI 3.1.c Plan and implement nutrition
interventions to include prioritizing the
nutrition diagnosis, formulating a nutrition
prescription, establishing goals and selecting
and managing.
DI 3.1.d Monitor and evaluate problems,
etiologies, signs, symptoms and the impact
of interventions on the nutrition diagnosis.
DI 2.6 Assign appropriate patient care ▪ Consult with social worker or other □ □
activities to DTRs and /or support personnel allied health professionals as needed. 4 3 2
considering the needs of the patient/client or □ 1 □
situation, the ability of support personnel,
jurisdictional law, practice guidelines and
policies within the facility.
DI 2.7 Refer clients and patients to other
professionals and services when needs are
beyond individual scope of practice.
DI 2.11 Establish collaborative relationships
with internal and external stakeholders,
including patients, clients, care givers,
physicians, nurses and other health
professionals, administrative and support
personnel to facilitate individual and
organizational goals.
630176.doc Page 47 [140455]

Other Competencies Planned Learning Experience Check if
Completed
Education ▪ Observe RD interview, counsel and □
chart on a minimum of one patient per
area.
Education ▪ Review activities with Supervising □
RD on a daily basis.
Education ▪ Observe dietitians in Children’s □
Rehabilitation Services Clinic and
feeding clinic.
Education ▪ Spend time observing the NNICU unit □
and RD.
Evaluation ▪ Turn in all written/oral assignments. □
Evaluation ▪ Review evaluations with preceptor □
and formulate future goals for
professional development.
Supervising RD Signature:
Date:
Intern Name:
Date:
630176.doc Page 48 [140455]