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Evaluations - > Evaluation Review

Evaluations Final Clinical Evaluation Form--Revised 4/2016
Evaluations NUR 4216L TGH SBN (11/8/2016)
Experience Tran, Tiffany ([email protected])

Change password Evaluator: Custodio, Editha ([email protected])

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5-Outstanding: Exceeds Standards
Exhibits above average performance of nursing care for this level student. The student is
proactive, self-directed, and consistently engaged in learning; needs minimal guidance; is
knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and
self-directed in approach to learning.

4-Satisfactory: Meets Standards

Exhibits average performance of nursing care for this level student. Functions with minimum
guidance. Demonstrates adequate knowledge and requires minimum assistance in applying
knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing
them.

3-Minimal
Exhibits minimal performance of nursing care for this level student. Functions safely with
moderate guidance. Demonstrates minimal knowledge and requires moderate assistance in
applying knowledge to skills. Requires some direction in recognizing and utilizing learning
opportunities. Often focuses on the task or own behavior, not on the patient.

2-Unsatisfactory
Requires intense guidance for the performance of activities at a safe level. Clinical performance
reflects difficulty in the provision of nursing care. Demonstrates gaps in necessary knowledge
and requires frequent or almost constant assistance in applying knowledge to skills. Requires
frequent and detailed instructions regarding learning opportunities. Focuses primarily on the
task or own behavior, not on the patient.

1-Unsafe to Practice
Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge
and skills and unable to integrate these into practice. Requires constant detailed instructions
regarding learning opportunities and is often unable to utilize them. Attempts activity or
behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the
patient.

Standard I--Communication

1. Communicates pertinent information regarding the patient's condition/concern to

health team members.
2. Communicates effectively in written form (Nursing Process Worksheet is organized
and complete)
3. Communicates effectively in verbal form.
4. Initiates, maintains, and terminates the nurse-patient relationship using principles
of therapeutic communication.
5. Functions as an advocate for the patient/family and communicates family needs to
other members of the health care team.
6. Examines the dynamic interactions between the patient, family, community, and
society.
7. Initiates discussion to identify and resolve interpersonal problems that impact
care.
8. Uses interpersonal skills to enhance patient/family coping abilities.
9. Discusses the ethical issues and approaches the ethical dilemmas that confront
the patient/family and appropriately discusses experience with faculty/preceptor.
10. Delegates appropriately to patient care technician, family, or other team members.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice

Utilizes effective communication skills. NPW is always neat, complete , and organized.

Standard I-Knowledge

1. Applies knowledge of humanities, physical and social sciences, and nursing when
providing patient care.
2. Applies knowledge of social, cultural, and genetic factors to the care of diverse
populations.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice

Standard I-Attitude

1. Consistently demonstrates professional behavior as indicated by preparedness for

rounds, contributing substantively to post conferences, respecting staff, faculty and
preceptors in communication and tone.
2. Provides clinical objectives to preceptor as determined in pre-conference.
3. Preparedness for the clinical day as indicated by timely arrival to clinical in the
required dress code.
4. Focused attention during post conference to peers as well as faculty.
5. Is actively engaged in and seeks out opportunities for learning.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice
Consistently demonstrates professional behavior at all times. Always ready to give patient report
during rounds. Seeks opportunities for learning.

Standard II-Safety

1. Does not make judgmental, discriminatory, or prejudicial statements to the patient,

staff, or faculty.
2. Applies principals of universal precautions, practices specific isolation techniques,
and teaches the reasons for universal precautions.
3. Assesses patients for fall risk and applies principles of safe patient handling.
4. Maintains the patient's physical safety by protecting the patient from harm.
5. Maintains medical and surgical asepsis when doing procedures requiring sterile
technique.
6. Properly identifies techniques and teaches the reasons for universal precautions.
7. Validates the accuracy and appropriateness of orders for nursing/medical care
prior to initiating care.
8. Implements orders accurately and efficiently.
9. Is able to identify potential signs and symptoms of an emergent medical condition
and promptly reports changes in the patient's health status to preceptor and/or
clinical faculty member.
10. Adapts skill performance using principles of theory when necessary.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice

provides care in a nonjudgmental and nondiscriminatory manner. Maintains patient safety at all times.

Standard III-Nursing Process: Assessment

1. Identifies data from the history and physical assessment to formulate appropriate
nursing diagnoses.
2. Identifies the patient's health education needs.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice
Standard III-Nursing Process: Diagnosis

1. Synthesizes history and assessment data as well as diagnostic results into the
development of nursing diagnoses.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice

Throughout the clinical rotation, Tiffany has been able to pick appropriate nursing diagnoses for her
assigned patients based on history and assessment data.

Standard III-Nursing Process: Plan

1. Integrates psychosocial needs into care plan, identifies appropriate resources for
the plan of care, and incorporates health education into the care plan.
2. Identifies measurable, expected patient outcomes that are realistic and
individualized to the patient.
3. Identifies the discharge planning process and needs of the patient upon admission
and throughout the hospitalization.
4. Demonstrates judgment in decision-making and priority setting.
5. Uses appropriate collaborative resources to personalize the nursing care the
patient receives.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice

Standard III-Nursing Process: Intervention/Implementation

1. Demonstrates understanding of the principles underlying nursing actions

appropriate for the student at this point in the curriculum.
2. Performs skills according to agency policy and procedure and clinical lab
guidelines.
3. Implements the written action plan/protocol considering the priorities for each
assigned patient.
4. Standard III-Nursing Process: Intervention/Implementation
5. Implements a teaching plan based on scientific knowledge and utilizes resources
appropriately.
6. Incorporates evidence based research into nursing practice.
7. Practices individualized and culturally competent care.
8. Initiates appropriate referrals as needed.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice

Standard III-Nursing Process: Evaluation

1. Evaluates the patient's response/outcome to the intervention.

2. Utilizes subjective and objective data to revise nursing actions (as appropriate for
the student at that level of the curriculum).
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice

Standard III-Nursing Process: Organization

1. Provides organized, coordinated, and prioritized nursing care for the patients with
a range of health problems.
2. Organizes time and resources effectively and efficiently.
3. Gathers and organizes equipment necessary for patient care/procedures.
4. Identifies and seeks appropriate resources during patient care provision.
5. Completes the daily clinical assignment in a timely manner.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice
 Submits assignments in a timely manner. Excellent organization skills.

Standard III-Nursing Process: Documentation

1. Appropriately develops long and short term patient oriented nursing care goals
based on patient assessment and scientific principles of nursing practice.
2. Documents problems and nursing care goals in the patient record (with co-
signature).
3. Identifies and documents nursing actions/orders initiated in implementing the plan
of care.
4. Correctly enters data into the patient record in a timely manner per agency
protocol.
5. Assures privacy of the patient record at all times.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice

Observes HIPAA policy at all times. Documents in the electronic medical record accordingly.

Standard III-Nursing Process: Critical Thinking

1. Utilizes critical thinking skills to prioritize patient needs based on the patient
assessment.
5 (Comment Required) Outstanding: Exceeds Standards
4 Satisfactory: Meets Standards
3 Minimal
2 (Comment Required) Unsatisfactory
1 (Comment Required) Unsafe to Practice

At this point, Tiffany is able to utilize critical thinking skills and it shows in her verbal report and
preceptor evaluation.

Comments:
 Well done this semester Tiffany! I can tell that you will be successful in this field. Your preceptors speak
highly of you and they also write it in the comments in your anecdotals. Keep up the good work and I
wish you all the best!

Tiffany Tran has reviewed the above evaluation on 12/10/2016 and has provided the
following comment:
Thank you again, Mrs. Custodio! You have been a wonderful and supportive clinical
instructor. Thank you for making yourself available to answer questions in and out of the
clinical setting. I look forward to utilizing and further developing the skills you have helped
me acquire.

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