Nutrition Care Self Assessment Tool Template
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2CDM, CFPP Nutrition Care self assessment tool
Name ________________________________________________________________________
Date of Review ____________________________
Qualification: CDM, CFPP
Yes
No
Competent
Skill
Yes
No
If No, Action Taken
Date
Current with certification as a CDM, CFPP
Aware of CBDM’s Scope of Practice, Professional Practice
Standards, and CBDM’s Continuing Education Requirements
C L I N I C A L A R E A
Able to assign patients to appropriate nutrition risk category using
facility-approved screening policy and procedure
Able to use the Model for CDM, CFPP Role in Nutrition Care Flow
Chart to determine appropriate action
Able to identify diagnoses which have nutritional implications and
document accordingly
Able to accurately record weight status (IBW, UBW, BMI, etc .)
Able to accurately record protein status utilizing facility-approved
guidelines
Able to estimate caloric needs appropriately, utilizing facility-
approved guidelines
Able to estimate protein needs appropriately, utilizing facility-
approved guidelines
Able to estimate fluid needs appropriately, utilizing facility-
approved guidelines
Able to follow facility guidelines for a change in diet order or
nutrition intervention if nutrition screening warrants this change
Refers needs for nutrition support (tube feeding, TPN) and high
nutrition risk patients to the RD, according to facility-approved
guidelines
Provides, or makes appropriate referrals for nutrition counseling,
utilizing facility-approved guidelines
N U T R I E N T I N TA K E S
Able to analyze food intake appropriately
Able to analyze macronutrients from PO feedings
D O C U M E N TAT I O N
Able to complete assigned sections of the RAI/Care Plan
accurately and timely utilizing facility-approved guidelines
Able to use Nutrition Notes and Nutrition Progress Notes
appropriately and timely
Able to implement nutritional interventions and document on the
Interdisciplinary Care Plan utilizing facility-approved guidelines
Able to communicate nutritional interventions or recommendations
in appropriate manner
Able to document on Discharge Summary appropriately
33
May • 2009
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