Nutrition Clinical Skill Checklist AgainstNoS (National Occupational Standard) and CC (Core Curriculum)

This form is to be used by observing students in Nutrition 2. Use the first shaded section for patient one, the second shaded section for patient two and so on until patient 9.

Hand this checklist in together with your portfolio by the end of the year.

Student Name: ...... Completion Date: ......

NOS Criteria Sections 1-9 / Example / Patient Number
Date of consultation / 1/11/09
Patient initials / TC
Initials of the student taking the case / JB
Initial (I) Follow-up (F) / I
1. Preparation and opening / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Consultation environment meets codes of practice plus health and safety / C
Preparation of an adequate work space; ventilation, lighting, heating, level of noise, privacy, space, cleanliness and orderliness,paper work ready. / C
Positions the patient to minimise risk of injury to self and others and optimise comfort to the patient / C
Appearance, dress, personal hygiene / NC
Introduces the patient and any companion(s) to any of those present and reminds of CCTV link (if applicable) and explains about the role of the clinical assistant and supervisor. / NC
Explains format & duration of consultation + fee structure / C
Informs patient of records to be made and stored confidentiality. / C
Encourages patient to ask questions during the consultation / NC
2. Gathering information (initial) / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Evaluates patients initial approach and manner (appearance, body language, behaviour, posture, gait) to clearly identify and refine their goals and concerns
Questions sensitively but in sufficient detail to identify significant aspects of patient’s condition & lifestyle.
Interprets the information needed to tailor further questioning to gain further information using knowledge of NT
Gathers significant information regarding the history of the patients health, functional status and well-being (physical, emotional, psychological) including any particular medical conditions, medication, accidents, surgery, vaccinations, birthing complications, supplements, herbs, previous treatments, red flag signs and symptoms, dietary and lifestyle information, social and family history / C
Uses safe and appropriate assessment methods such as dietary analysis, case history questionnaires, functional testing or anthropometric analysis which are considered safe and appropriate to the patients presenting condition and comply with professional and legal requirements / C
C
Identifies red flags / contraindication to NT and need for referral to other medical/healthcare professionals and where NT is not suitable
Use appropriate naturopathic diagnostic skills – hair, nails, iris, tongue, etc
3. Gathering information (follow up) / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Evaluates the patients progress re symptoms – improved/not improved/deteriorated/ not changed.
Questions patient to assess implementation of treatment plan to identify compliance and ease or difficulty of programme.
Encourages the patient to evaluate the plan and suggest possible areas of modification
Interprets the information gained to tailor further questioning to gain further information using knowledge of NT
Confirms patients current goals are unchanged or reassesses new health goals
4. Explanation of findings / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Explains possible nutritional and lifestyle factors influencing the patients health.
Clearly links nutritional and lifestyle factors to signs and symptoms
Ensures the information is sufficient to advise and educate the patient
Refers to other medical/health careprofessional if necessary
Motivates the patient by identifying improvements already achieved and sensitively explain the importance of compliance
5. Protocol / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Negotiates treatment plan to meet the patients identified needs, goals and condition and preferences
Ensures treatment takes into consideration the patients personal, cultural and social situation
Provides clear, comprehensive, suitable and accurate dietary advice to the patient
Provides clear, comprehensive, suitable and accurate neutraceutical advice to the patient
Provides clear, comprehensive, suitable and accurate advice regarding functional tests/functional test results to the patient
Provides clear, comprehensive, suitable and accurate lifestyle advice to the patient
Discusses any restrictions or contraindications to NT and unrealistic expectations
Provides handouts where appropriate to back up the consultation but not to be relied upon as an alternative to explanations.
Minimises the risk of side effects or interactions with any medication – prescribed and/or OTC
Informs patient of any possible risk(s) or side effect(s) associated with the treatment plan and advise of action to be taken re side effects or concerns
Discusses and explains the duration of the treatment plan
Discusses costs of treatment plan sensitively with consideration for patients financial situation.
Checks understanding with the patient
Responds suitably to patients questions
Negotiates appropriate adjustments to the treatment plan to meet the patients goal (new and old)
6. Closing the consultation / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Checks overall understanding of the implementation of treatment plan and [potential] outcomes
Encourages any final questions
Encourages the patient to record effects of the treatment plan for future review
Discusses and agree how the treatment plan will be evaluated
Books and arrange next appointment
Delivers a rounded consultation within allocated time
Advises the patient on appropriate action to take if concerns arise whilst using the self-care procedure(s)
7. Communication and motivation / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Ensures the pace and level of the consultation are suitable for the patient to assure understanding and completion of the treatment plan.
Communicates effectively using a variety of methods and in a manner that builds and maintains patients trust and confidentiality, builds rapport and encourages patient participation.
Conducts the assessment in a manner which encourages the effective participation of the patient taking into consideration the patient’s personal, cultural and social situation.
Relates to companion(s) of the patient appropriately.
Informs patient as consultation progresses about what is happening next.
8. Professionalism / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Respects the patient and his/her needs and privacy throughout the consultation
Explains to the patient potentialconsequences of not following the treatment plan
Respects the patients right not to adopt any of the treatment plan
Displays respect to all during clinic time – tutors, fellow students and patients and any companion(s)
Seeks support and advice when the needs of the patient or complexity of the case are beyond your knowledge, remit or experience
Obtains the patients permission to pass on confidential information to others where further information is needed
Stops the consultation if the patient requests this or if information gathered makes it unsafe to continue
9. Notes and record keeping / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Completes accurate, legible and comprehensive consultation notes during the consultation
Creates accurate, legible and comprehensive notes for the patient during the consultation including name date, appointment number, length of plan
Checks patient understands notes
Stores records securely in CNM dispensary or in lockable storage.
Does not take a photocopy of notes to work from at home – uses patient synopsis for this.