APPENDIX I – Clinical Evaluation Process
FACULTY COMMENTS
Areas That Exceed Expectation
Areas That Need Improvement
Areas That Exceed Expectation
Areas That Need Improvement
Signatures
Student:_____________________________________________
Faculty:_____________________________________________
Student:_____________________________________________
Faculty:_____________________________________________
Date
Approved by UPC 12.3.2012
Page: 64 of 99
Student’s Name ___________________________________
Semester/Year/Rotation ____________________________
CLINICAL EVALUATION TOOL Purpose: To evaluate student performance in the clinical setting.
Evaluation Guidelines:
5. Student will review clinical evaluation expectations during orientation to the clinical unit, discuss objectives, and goals.
6. Instructor and student will meet at midterm for a formative assessment of student’s progress to meet goals.
7. End of the semester outcome evaluations will be documented as (a) needs opportunity, (b) satisfactory, and (c) unsatisfactory.
8. Clinical behaviors that are bold and italicized are considered critical behaviors – two unsatisfactory critical behaviors would result in a failure for the entire course.
Evaluation Criteria:
Acknowledges that clinical behaviors are the foundation for the provision of health care, these behaviors are evaluated by Needs opportunity/Satisfactory/Unsatisfactory. Any critical clinical behavior designated as unsatisfactory is to be identified and documented in detail on the Clinical Failure Document*. A designation of unsatisfactory in any other behaviors should be documented in detail in the comments section of this form.
*Refer to the SON undergraduate handbook
SAFETY N S U N S U
Successfully passes medication administration test with a score of 100 prior to beginning clinical rotation (3 attempts permitted)*
Attempts: 1 □ 2 □ 3 □
Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
Medication Administration N S U N S U
Administers medications based on scientific knowledge and knowledge of nursing implications
Administers medications in accordance with the seven rights
(right: drug, client, dose, time, route, reason, and documentation) PO
SQ IV:
Course NURS 3510 Midterm
Final
a. Push b. Piggyback Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
Patient Safety N S U N S U
Maintains physical patient safety
Wears appropriate personal protective equipment
Protecting Self & Others N S U N S U
Appropriate disposal of contaminated waste and sharps
Follows safety/ infection prevention policies & protocols of agency
PROFESSIONALISM N S U N S U
Is present, punctual and prepared for clinicals
Maintains civility with peers, staff, instructor and patients Follows dress code
Is accountable for actions and non-actions
Assignments completed at level appropriate and turned in on time Demonstrates cultural competence and sensitivity
COMMUNICATION N S U N S U
Engages in therapeutic communication with patients
Reports changes in patient condition to primary RN and instructor Adheres to agency HIPAA procedures and guidelines
Collaborates with instructor and healthcare team Receives and gives shift report
PATIENT CENTERED CARE N S U N S U
Nursing Process in the Care of Adult Medical Surgical Patients N S U N S U Performs and documents an accurate patient assessment
Incorporates the pathophysiological basis of conditions to patient assessment findings, laboratory and diagnostic test results Develops appropriate nursing diagnosis
Identifies mutually measurable goals with patient and staff Identifies and implements timely and appropriate interventions Evaluates client response to interventions
Care of two adult medical surgical patients N S U N S U
Page: 66 of 99
Organizes and prioritizes time and interventions appropriately for two patients
Administers medications to two patients
Teaching and Learning N S U N S U
Identifies educational needs, determines learning readiness of patient and implements education as necessary
Completes teaching presentation to peers and/or staff
Participates in post-conference debriefing with instructor and peers
CRITICAL THINKING N S U N S U
Database/Careplan N S U N S U
Nursing implications and interventions show evidence of critical thinking
Patient Care N S U N S U
Functions within the scope of practice of a student nurse Uses evidence based information to formulate and implement nursing interventions
Seeks help when needed
MIDTERM FINAL
STUDENT COMMENTS
Areas That Exceed Expectation
Areas That Need Improvement
Areas That Exceed Expectation
Areas That Need Improvement
FACULTY COMMENTS
Areas That Exceed Expectation
Areas That Need Improvement
Areas That Exceed Expectation
Areas That Need Improvement
Signatures
Student:_____________________________________________
Faculty:_____________________________________________
Student:_____________________________________________
Faculty:_____________________________________________
Date
Approved by UPC 12.3.2012
Page: 68 of 99
Student’s Name Course NURS 3810
Semester/Year/Rotation Midterm
Final
CLINICAL EVALUATION TOOL
Purpose: To evaluate student performance in the clinical setting.
Evaluation Guidelines:
1. Student will review clinical evaluation expectations during orientation to the clinical unit, discuss objectives, and goals.
2. Instructor and student will meet at midterm for a formative assessment of student’s progress to meet goals.
3. End of the semester outcome evaluations will be documented as (a) needs opportunity, (b) satisfactory, and (c) unsatisfactory.
4. Clinical behaviors that are bold and italicized are considered critical behaviors – two unsatisfactory critical behaviors would result in a failure for the entire course.
Evaluation Criteria:
Acknowledging that clinical behaviors are the foundation for the provision of health care, these behaviors are evaluated by Needs opportunity/Satisfactory/Unsatisfactory. Any critical clinical behavior designated as unsatisfactory is to be identified and documented in detail on the Clinical Failure Document*. A designation of unsatisfactory in any other behaviors should be documented in detail in the comments section of this form.
*Refer to the SON undergraduate handbook
SAFETY N S U N S U
Successfully passes medication administration test with a score of 100 (3 attempts permitted)*
Attempts: 1 □ 2 □ 3 □
Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
Medication Administration N S U N S U
If medications are given, follows 7 rights and medication policies of agency (right: drug, client, dose, time, route, reason, and documentation)
Patient Safety N S U N S U
Wears personal protective equipment as needed Understands and follows standard precautions Maintains personal and patient safety
Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
Protecting Self and Others N S U N S U
Follows safety procedures and protocols of agency Disposes contaminated waste and sharps in proper containers
PROFESSIONALISM N S U N S U
Adheres to appropriate university, school, and agency policies, procedures, and protocols
Is present, punctual, and prepared for clinical Maintains professional attitude and behavior (professional dress)
Completes assignments on time and to appropriate level Attends required 12-step and support group and writes paper Is accountable for actions and non-actions
Demonstrates cultural competence
Demonstrates caring and sensitivity to the dignity and values of of patient
Maintains ethical patient-centered care Uses journals to self-reflect
Identifies strengths and challenges Set and achieves personal goals
COMMUNICATION N S U N S U
Interacts with patients, staff, peers, and faculty professionally and therapeutically
Reports pertinent information to staff/instructor Reports off at end of shift
Follows HIPPA and confidentiality procedures of agency Uses non-judgmental therapeutic communication
Is aware of personal space and effect of body language Uses appropriate terminology for level of knowledge Completes a Process Recording (e.g. demonstrates effective communication techniques, identifies barriers to communication) Interacts with social services, physician, nurses, and staff to gain understanding of patients’ needs
Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
PATIENT CENTERED CARE N S U N S U
Page: 70 of 99
Nursing Process N S U N S U
Performs and documents an accurate assessment of patient Identifies pertinent nursing diagnosis on care plans Identifies measurable and realistic goals on care plan and collaborates with patient to accomplish
Implements timely interventions (e.g. assesses the effectiveness and adverse effects of their patients’ medications and documents)
Evaluates patients’ responses to goals and interventions Assists unit to monitor vital signs as needed
Helps maintain positive therapeutic environment
Applies biopsychosocial and developmental theories/models to improve patients’ health
Incorporates legal, ethical, and socio- economic considerations in providing care
Demonstrates organizational skills
Integrates information technology to enhance the delivery of health care to patients
Teaching and Learning N S U N S U
Educates patients on medications, disorders and other treatments and procedures
Safely Cares for Two Patients
CRITICAL THINKING N S U N S U
Utilizes effective decision-making skills to enhance patients’
health
Practices within scope of student nurses’ practice Seeks assistance when needed
Utilizes nursing knowledge through demonstration of competent knowledge
Participates in evidence-based practice assignment and utilizes knowledge for care of patients
Presents case study/vignette to clinical group
MIDTERM FINAL
STUDENT COMMENTS
Areas That Exceed Expectation
Areas That Need Improvement
Areas That Exceed Expectation
Areas That Need Improvement
FACULTY COMMENTS
Areas That Exceed Expectation
Areas That Need Improvement
Areas That Exceed Expectation
Areas That Need Improvement
Signatures
Student:__________________________________________
Faculty:__________________________________________
Student:___________________________________________
Faculty:___________________________________________
Date
Approved by UPC 12.3.2012
Page: 72 of 99
Student’s Name Course NURS 3610
Semester/Year/Rotation Midterm
Final
CLINICAL EVALUATION TOOL Purpose: To evaluate student performance in the clinical setting.
Evaluation Guidelines:
1. Student will review clinical evaluation expectations during orientation to the clinical unit, discuss objectives, and goals.
2. Instructor and student will meet at midterm for a formative assessment of student’s progress to meet goals.
3. End of the semester outcome evaluations will be documented as (a) needs opportunity, (b) satisfactory, and (c) unsatisfactory.
4. Clinical behaviors that are bold and italicized are considered critical behaviors – two unsatisfactory critical behaviors would result in a failure for the entire course.
Evaluation Criteria:
Acknowledging that clinical behaviors are the foundation for the provision of health care, these behaviors are evaluated by Needs opportunity/Satisfactory/Unsatisfactory. Any critical clinical behavior designated as unsatisfactory is to be identified and documented in detail on the Clinical Failure Document.* A designation of unsatisfactory in any other behaviors should be documented in detail in the comments section of this form.
*Refer to the SON undergraduate handbook
SAFETY N S U N S U
Successfully passes medication administration test with a score of 100 prior to beginning clinical rotation (3 attempts permitted)*
Attempts: 1 □ 2 □ 3 □
Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
Medication Administration N S U N S U
Follows 7 rights of medication administration (right: drug, client, dose, time, route, reason, and documentation)
Administered meds when caring for two patients
Shows appropriate medication knowledge and understanding of nursing implications as it relates to medication
Patient Safety N S U N S U
Uses appropriate PPE
Maintains physical patient safety
Protecting Self and Others N S U N S U
Appropriately disposes of contaminated waste and sharps
Follows safety and infection prevention policies and protocols of clinical agency
Instructions: MIDTERM FINAL
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
PROFESSIONALISM N S U N S U
Is punctual and prepared for clinical
Maintains civility with peers, staff, instructor, and patients Maintains professional attitude and behavior in all interactions Is accountable for actions and non-actions
Seeks guidance appropriately when unsure of clinical course of action
Demonstrates ethical and culturally sensitive care Completes and turns in assignments in a timely manner Accepts constructive criticism and incorporates feedback into performance
Adheres to appropriate university and agency policies and protocols
COMMUNICATION N S U N S U
Collaborates with instructor and healthcare team in a professional manner
Adheres to HIPPA and clinical agency confidentiality procedures Reports any changes in patient condition to primary RN and instructor
Engages in therapeutic communication with patients and families Receives and gives shift report using appropriate terminology
PATIENT CENTERED CARE N S U N S U
Nursing Process N S U N S U
Completes assigned Databases/Careplans Develops appropriate Nursing Diagnoses
Identifies mutually measurable goals with patient and staff Evaluates patient response to interventions
Revises interventions as necessary
Teaching and Learning N S U N S U
Completes teaching presentation for peers and/or staff
Identifies educational needs of patient and family, and implements education as necessary using a family-centered and culturally appropriate approach
Participates in post-conference debriefing with instructors and peers Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
Safely Cares for Two Patients (Mother and Newborn) N S U N S U
Page: 74 of 99
Monitors and documents vital signs and I&O on mother and baby, and acts on the results appropriately
Follows safety procedures related to newborn/mother separation and identity per institution policy
Performs and documents an accurate assessment of mother and baby Administers meds to both patients as needed
Organizes and prioritizes time appropriately for both patients Integrates information technology to enhance the delivery of health care to both patients and their family
Shows cultural awareness appropriately in direct patient contact and during family-centered care
Integrates pathophysiologic basis of conditions(s) to patient assessment findings, laboratory and diagnostic test results, and medications and acts on these findings appropriately for knowledge level
CRITICAL THINKING N S U N S U
Database/Careplan nursing implications and interventions show evidence of critical thinking
Patient Care N S U N S U
Uses evidence-based information to formulate nursing interventions Seeks assistance appropriately from either primary RN, staff or instructor
Maintains patient dignity and privacy as culturally appropriate while administering care
Recognizes personal limitations of knowledge and seeks appropriate resources
Approved by UPC 12.3.2012
MIDTERM FINAL
STUDENT COMMENTS
Areas That Exceed Expectation
Areas That Need Improvement
Areas That Exceed Expectation
Areas That Need Improvement
FACULTY COMMENTS
Areas That Exceed Expectation
Areas That Need Improvement
Areas That Exceed Expectation
Areas That Need Improvement
Signatures
Student:_____________________________________________
Faculty:_____________________________________________
Student:_____________________________________________
Faculty:_____________________________________________
Date
Page: 76 of 99
Student’s Name Course NURS 3710
Semester/Year/Rotation Midterm
Final
CLINICAL EVALUATION TOOL
Purpose: To evaluate student performance in the clinical setting.
Evaluation Guidelines:
9. Student will review clinical evaluation expectations during orientation to the clinical unit, discuss objectives, and goals.
10. Instructor and student will meet at midterm for a formative assessment of student’s progress to meet goals.
11. End of the semester outcome evaluations will be documented as (a) needs opportunity, (b) satisfactory, and (c) unsatisfactory.
12. Clinical behaviors that are bold and italicized are considered critical behaviors – two unsatisfactory critical behaviors would result in a failure for the entire course.
Evaluation Criteria:
Acknowledges that clinical behaviors are the foundation for the provision of health care, these behaviors are evaluated by Needs opportunity/Satisfactory/Unsatisfactory. Any critical clinical behavior designated as unsatisfactory is to be identified and documented in detail on the Clinical Failure Document*. A designation of unsatisfactory in any other behaviors should be documented in detail in the comments section of this form.
*Refer to the SON undergraduate handbook
SAFETY N S U N S U
Successfully passes medication administration test with a score of 100 prior to beginning clinical rotation (3 attempts permitted)*
Attempts: 1 □ 2 □ 3 □
Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
Medication Administration N S U N S U
Administers medications based on scientific principles and knowledge of nursing implications.
Administers medications in accordance with the seven rights (right: drug, client, dose, time, route, reason, and documentation)
Considers growth and developmental principles with medication administration
PO SQ
IM IV
c. Push
d. Medication Syringe Pump or Piggyback
Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
Patient Safety N S U N S U
Maintains physical patient safety
Wears appropriate personal protective equipment
Protecting Self & Others N S U N S U
Appropriately disposes contaminated waste and sharps
Follows safety and infection prevention policies and protocols of agency
PROFESSIONALISM N S U N S U
Is present, punctual, and prepared
Maintains civility with peers, staff, instructor, and patients Follows dress code
Is accountable for actions and non-actions
Accepts constructive criticism and incorporates such feedback for improvement of performance
Appropriately self-reflects as pertaining to strengths and limitations with care provided to patients and families
Assignments completed at appropriate level and submitted on time Demonstrates cultural competence and sensitivity
COMMUNICATION N S U N S U
Engages in therapeutic communication with patients Reports changes in patient condition to primary nurse and instructor
Adheres to agency HIPAA procedures and guidelines Receives and gives report
Page: 78 of 99
Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
PATIENT CENTERED CARE N S U N S U
Nursing Process in the Care of Children, Adolescents and their Families
N S U N S U
Performs and documents accurate assessment
Incorporates the pathophysiological basis of conditions with patient assessment findings, laboratory and diagnostic test results Develops appropriate nursing diagnoses
Identifies mutually measurable goals with patient and staff Evaluates client response to interventions
Cares for up to two patient(s) and families N S U N S U Organizes and prioritizes time and interventions appropriately for
one to two patients
Appropriately administers medications to all patients
Teaching and Learning N S U N S U
Identifies educational needs, growth and developmental level, learning readiness of patient and implements education as necessary
Participates in pre and/or post-conference debriefing with instructor and peers
CRITICAL THINKING N S U N S U
Database/Care Plan N S U N S U
Nursing implications and interventions show evidence of critical thinking
Patient Care N S U N S U
Seeks help when needed
Functions within the scope of practice of a student nurse Utilizes applicable research and/or evidence based information to formulate and implement nursing interventions
MIDTERM FINAL
STUDENT COMMENTS
Areas That Exceed Expectation
Areas That Need Improvement
Areas That Exceed Expectation
Areas That Need Improvement
FACULTY COMMENTS
Areas That Exceed Expectation
Areas That Need Improvement
Areas That Exceed Expectation
Areas That Need Improvement
Signatures
Student:_____________________________________________
Faculty:_____________________________________________
Student:_____________________________________________
Faculty:_____________________________________________
Date
Approved by UPC 12.3.2012
Page: 80 of 99
Student’s Name Course NURS 4510
Semester/Year Midterm
Final ________
CLINICAL EVALUATION TOOL Purpose: To evaluate student performance in the clinical setting.
Evaluation Guidelines:
1. Student will review clinical evaluation expectations during orientation to the clinical unit, discuss objectives, and goals.
2. Instructor and student will meet at midterm for a formative assessment of student’s progress to meet goals.
3. End of the semester outcome evaluations will be documented as (a) needs opportunity, (b) satisfactory, and (c) unsatisfactory.
4. Clinical behaviors that are bold and italicized are considered critical behaviors – two unsatisfactory critical behaviors would result in a failure for the entire course.
Evaluation Criteria:
Acknowledging that clinical behaviors are the foundation for the provision of health care, behaviors are evaluated by Needs opportunity/Satisfactory/Unsatisfactory. Any critical clinical behavior designated as unsatisfactory is to be identified and documented in detail on the Clinical Failure Document*. A designation of unsatisfactory in any other behaviors should be documented in detail in the comments section of this form.
*Refer to the BFLSON undergraduate handbook Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
SAFETY N S U N S U
Administers medications based on scientific knowledge and in accordance with the 7 rights of medication administration (right:
patient, medication, dose, rout, time, reason, & documentation) (when opportunity is available)
Provides current, evidence-based medication education
Client Safety N S U N S U
Communicates client status to instructor in a timely manner Follows standard precautions at all times
Maintains physical patient safety
Wears appropriate personal protective equipment
Protecting Self & Others N S U N S U
Follows clinical site guidelines for client interactions Follows agency safety and infection prevention policies and protocols
Adheres to personal safety measures
Instructions:
Check one of the following for each clinical behavior listed at the midterm and final evaluation of the clinical experience:
N – Needs Opportunity; S – Satisfactory; U – Unsatisfactory
MIDTERM FINAL
Disposes contaminated waste and sharps appropriately
PROFESSIONALISM N S U N S U
Is present, punctual and prepared for clinical and team meetings Maintains civility with peers, staff, instructor and patients Follows dress code
Is accountable for actions/non actions Provides ethical and culturally sensitive care Demonstrates ability to work effectively in teams Engages in personal self-reflection and group reflection Submits assignments in a timely manner
COMMUNICATION N S U N S U
Engages in therapeutic communication with patients Reports client findings to faculty as indicated
Adheres to agency HIPAA procedures and guidelines
Adheres to agency HIPAA procedures and guidelines