Clinical Performance Evaluation Form

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CLINICAL PERFORMANCE EVALUATION FORM
The faculty liaison, in collaboration with the student’s preceptor will evaluate the student based
on the following criteria at the completion of the practicum. Each evaluation will be assessed
according to the following performance criteria:
4 – Exemplary – Meets and exceeds expected standards consistently
3 – Competent – Meets expected standards*
2 – Fair – Meets expected standards inconsistently
1 – Inadequate – Does not meet expected standards
ANY INADEQUATE RATING WILL RESULT IN COUNSELING, AND
POSSIBLE FAILURE OF PRACTICUM.
*ALL competencies under Course/Program Outcome #3 must be performed at a
competent level or better to successfully complete the program.
The total score represents 30% of the student’s final grade.
Student_____________________Facility/Unit__________________Date___________
Preceptor__________________________________________
Faculty Liaison______________________________________
Please write the score for each objective on the line provided.
Course/Program Outcome #1
Interact appropriately through verbal, nonverbal, and written communication with
patients, families, and members of the health care team.
1.1) Utilize effective communication skills when interacting with clients, significant others, and
healthcare team.
_____
1.2) Communicate relevant, accurate and complete information in a concise and clear
manner.
_____
1.3) Report and document assessments, interventions and progress toward client
outcomes.
_____
1.4) Utilize appropriate channels of communication to achieve positive client
outcomes.
_____
1.5) Utilize information technology to support and communicate the planning and
provision of client care.
_____
1.6) Delineate and maintain appropriate professional boundaries in the nurse-client
relationship.
_____
NU: Sp ’13 Adopted. July ‘13 REV.
1
CLINICAL PERFORMANCE EVALUATION FORM
The faculty liaison, in collaboration with the student’s preceptor will evaluate the student based
on the following criteria at the completion of the practicum. Each evaluation will be assessed
according to the following performance criteria:
4 – Exemplary – Meets and exceeds expected standards consistently
3 – Competent – Meets expected standards*
2 – Fair – Meets expected standards inconsistently
1 – Inadequate – Does not meet expected standards
ANY INADEQUATE RATING WILL RESULT IN COUNSELING, AND
POSSIBLE FAILURE OF PRACTICUM.
*ALL competencies under Course/Program Outcome #3 must be performed at a
competent level or better to successfully complete the program.
The total score represents 30% of the student’s final grade.
Student_____________________Facility/Unit__________________Date___________
Preceptor__________________________________________
Faculty Liaison______________________________________
Please write the score for each objective on the line provided.
Course/Program Outcome #1
Interact appropriately through verbal, nonverbal, and written communication with
patients, families, and members of the health care team.
1.1) Utilize effective communication skills when interacting with clients, significant others, and
healthcare team.
_____
1.2) Communicate relevant, accurate and complete information in a concise and clear
manner.
_____
1.3) Report and document assessments, interventions and progress toward client
outcomes.
_____
1.4) Utilize appropriate channels of communication to achieve positive client
outcomes.
_____
1.5) Utilize information technology to support and communicate the planning and
provision of client care.
_____
1.6) Delineate and maintain appropriate professional boundaries in the nurse-client
relationship.
_____
NU: Sp ’13 Adopted. July ‘13 REV.
1
Course/Program Outcome #2
Coordinate and collaborate with the interdisciplinary health care team to assess patients
and provide direct nursing care that promotes optimal wellness of clients throughout the
lifespan.
2.1) Coordinate the decision making process with the client, significant others, and
other members of the health care team.
_____
2.2) Work cooperatively with others to achieve client outcomes.
_____
2.3) Collaborate with the client, significant others, and health care team to
evaluate progress toward achievement of outcomes.
_____
2.4) Interact creatively and openly with others to solve problems to achieve
client goals and outcomes.
_____
2.5) Facilitate the continuity of client care.
_____
2.6) Delegate aspects of client care to qualified assistive personnel.
_____
2.7) Supervise and evaluate the activities of assistive personnel.
_____
Course/Program Outcome #3*
Demonstrate competent and safe implementation of clinical nursing skills in
meeting clients’ psychosocial and physiological needs.
3.1) Provide a safe physical and psychosocial environment.
_____
3.2) Assess the client’s health status by completing an admission history and
physical.
3.3) Assess the client’s response to actual and potential health problems
_____
3.4) Use standards of nursing practice to perform and evaluate client care.
_____
3.5) Implement appropriate JCAHO patient safety goals; i.e. identify patients
correctly, improve staff communication, administer medications
safely, prevent infection, check patient medications, identify patient
safety risks.
_____
3.6) Practice within the parameters of individual knowledge and experience.
_____
3.7) Perform nursing skills competently.
_____
3.8) Assess the client’s response to interventions.
_____
3.9) Assist the client to achieve optimum comfort and functioning, including
the pharmacological management of pain.
_____
3.10) Demonstrate competence with current technologies.
_____
Course/Program Outcome #4
Provide compassionate and culturally sensitive care to a diverse population that personifies
the core values and ethics of the nursing profession.
4.1) Practice within the ethical, legal and regulatory frameworks of nursing and
standards of professional nursing practice.
_____
4.2) Assess the developmental, emotional, cultural, religious and spiritual influences
on the client’s health status.
_____
4.3) Advocate for client rights.
_____
4.4) Maintain client confidentiality.
_____
NU: Sp ’13 Adopted. July ‘13 REV.
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4.5) Protect and promote the client’s dignity.
_____
4.6) Demonstrate caring behavior towards the client, significant others, peers
and other members of the healthcare team.
_____
4.7) Implement the prescribe care regimen for management of clients within the
legal and ethical and regulatory framework of nursing practice.
_____
4.8) Adapt care in consideration of the client’s values, customs, culture and/or
habits.
_____
Course/Program Outcome #5
Demonstrate effective clinical judgment and decision making utilizing critical thinking
supported by scientific knowledge and evidence based practice.
5.1) Assess the client for changes in health status and identified needs.
_____
5.2) Prioritize client care.
_____
5.3) Implement an individualized plan of care.
_____
5.4) Make clinical judgments and management decisions to ensure accurate and
safe care.
_____
5.5) Analyze and utilize assessment and reassessment data to plan care.
_____
5.6) Evaluate the effectiveness of care provided in meeting client outcomes.
_____
5g) Modify client care as indicated by the evaluation of outcomes.
_____
5h) Use evidence-based information collected electronically or through other
means to support clinical decision making.
_____
Course/Program Outcome #6
Implement client/family centered teaching plans that promote self-care and optimal health.
6.1) Assess client and significant others for learning strengths, capabilities, barriers,
and educational needs.
_____
6.2) Develop an individualized teaching plan based on assessed needs.
_____
6.3) Teach the client and significant others the information and skills needed
to achieve the desired learning outcomes.
_____
6.4) Evaluate the progress of the client and significant others toward achievement
of the identified learning outcomes.
_____
6.5) Modify the teaching plan based on evaluation of progress toward meeting
the learning outcomes.
_____
TOTAL POINTS EARNED
____________
Student’s grade for this evaluation: ______(total points) /132 = _______%
Ex. Total points = 119
119/132 = 90%
NU: Sp ’13 Adopted. July ‘13 REV.
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Additional Comments:
Student:
____________________________
_____________
Signature
Date
Preceptor:
____________________________
______________
Signature
Date
Faculty Liaison
____________________________
_______________
Signature
Date
Evaluation Criteria based on Florida Department of Education Student Performance
Standards for Associate Degree Nursing Graduates. July, 2008
NU: Sp ’13 Adopted. July ‘13 REV.
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NU: Sp ’13 Adopted. July ‘13 REV.
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