Evaluation for Diet Interview

Part I: Directions

  1. Score each item by the number corresponding to the response most accurately describing the student’s performance.

2= student completed item as stated

0= student did not complete the item as stated

  • All 0’s must have documentation explaining and/or giving examples of how the student failed to meet the standard.

 

Part I: Standards

1.    Student utilizes time appropriately by scheduling a time for the interview.

2= student completed the item as stated

0= student did not complete the item as stated

Comments:

  • Student addresses patient by name using appropriate title.

2= student completed the item as stated

     0= student did not complete the item as stated

Comments:

  • Student introduces self appropriately by name and title.

2= student completed the item as stated

0= student did not complete the item as stated

Comments:

  • Student ensures the proper environment for the interview (i.e. appropriate setting, lighting, privacy)

2= student completed the item as stated

0= student did not complete the item as stated

Comments:

  • Student explains the purpose for the interview and for obtaining a diet history.

2= student completed the item as stated

0= student did not complete the item as stated

Comments:

  • Student demonstrates the ability to conduct interview without referring to the “form” or paper to cause distraction.

2= student completed the item as stated

0= student did not complete the item as stated

Comments:

  • Student uses time effectively, efficiently, and does not inappropriately rush or prolong the interview.  (Suggested time for in-depth interview 30-45 minutes).

2= student completed the item as stated

0= student did not complete the item as stated

Comments:

  • Student closes the interview by preparing the patient for closure by making plans for the next contact for any additional arrangements for follow-up care.  

2= student completed the item as stated

0= student did not complete the item as stated

Comments:

Part II: Directions

  1. Score each item by the number corresponding to the response most accurately describing the student’s performance.
  2. All 0’s must have documentation explaining and/or giving examples of how the student failed to meet the standard.

Part II: Standards

  1. Student uses the appropriate non-verbal communication skills during the interview:  facial expressions, voice (quality and loudness), maintaining eye contact, physical body position (faces patient at eye level if possible).

3- consistently utilizes appropriate skills throughout the interview

2- utilizes the appropriate skills with 1-2 errors

  1. makes 3 errors in non-verbal communication skills
  2. makes more than 3 errors in non-verbal communication skills

Comments:

  • Student appropriately investigates vitamin, mineral, food supplement or herbal usage/composition, length of use and dose.

3-  thoroughly investigates vitamin, mineral, food supplement and herbal use

  • investigates vitamin, mineral, food supplement and herbal use with one omission
  • investigates vitamin, mineral, food supplement and herbal use with two omissions
  • investigates vitamin, mineral, food supplement and herbal use with more than two omissions

Comments:

  • Student uses effective questioning skills such as open-ended questions and closed questions where appropriate.

3- consistently uses effective questioning skills throughout the interview

  • uses effective questioning skills with 1-2 errors

1-  makes 3 errors in using effective questioning skills

  • makes more 3 errors in using effective questioning skills

Comments:

  • Student uses language appropriate to patient’s ability to understand
  • consistently uses appropriate language throughout the interview

2-  uses appropriate language with 1-2 errors

  1. makes 3 errors in using appropriate language

0-  makes more than 3 errors in using appropriate language

Comments:

  • Student avoids using ineffective communication skills such as: wording question with an implied answer, combining two questions into one, monopolizing discussion, expressing own values/bias/attitudes.

3-  avoids using ineffective communication skills throughout the interview

  • uses ineffective communication skills 1-2 times during the interview
  • uses ineffective communication skills 3 times during the interview

0-  uses ineffective communication skills more than 3 times during the       

     interview

Comments:

  • Student can maintain control of the interview by redirecting patient’s inappropriate discussions, directing questions smoothly to reach closure, and probing into patient’s response incongruencies.
  • maintains control throughout the interview
  • maintains control with 1-2 errors during the interview
  • makes 3 errors in maintaining control of the interview
  • loses total control (more than 3 errors) of the interview

Comments:

  • Student demonstrates active listening skills by including the following as appropriate: restatement of patient’s words, appropriate silences and pauses to demonstrate interest and concern, and interpretation of patient’s “story” to better determine patient’s needs/concerns.
  • demonstrates skills consistently throughout the interview
  • demonstrates skills with 1-2 errors
  • demonstrates skills with 3 errors

0-  has difficulty with listening skills and makes more than 3 errors

Comments:

  • Student demonstrates ability to enhance communication process by the following: encouraging patient to continue, exploratory questioning to gain more detailed insight, empathy to patient’s problems, and self-disclosure (as appropriate).
  • demonstrates ability to enhance communication process consistently throughout the interview
  • demonstrates ability to enhance communication process with 1-2 errors
  • demonstrates ability to enhance communication process with 3 errors
  • has difficulty with the communication process and makes more than 3 errors

Comments:

  • Student provides the patient the opportunity to verbalize concerns and describe problems in appropriate detail.
  • consistently allows patient to discuss concerns and problems as     appropriate
  • allows patient to discuss concerns and problems with 1-2 errors
  • allows patient to discuss concerns and problems but not in sufficient detail   or in excess of what is needed to complete the interview, making 3 errors
  • does not allow patient to express concern or problems (more than 3 errors)

Comments:

__/43=__ % Total score for all pages

General Comments:

__________________    _____        _________________     _____

Student Signature           Date          Evaluator Signature   Date

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