Download CLINICAL EVALUATION FORM_FINAL

Clinical Evaluation
N124L IN
Summer 2013
CLINICAL EVALUATION FORM
STUDENT:
INSTRUCTOR:
FACILITY:
CLINICAL DATES:
DAY 1:
DAY2:
CLINCAL EVALUATION
UNIVERSAL PRECAUTIONS
Student arrives prepared physically and mentally for nursing care and
has preparatory paperwork complete
Completes care with regard for safety and infection control
PATIENT INTERACTION
Demonstrates therapeutic interactions
Demonstrates therapeutic listening
Provides social stimulation
Respect, provides dignity and observes cultural aspects for all
interactions
CRITICAL DECISION MAKING
Demonstrates understanding of diagnosis and pathophysiology
Integrates theory component into practice
Demonstrates problem solving skills
Demonstrates patient/resident understanding of medications
administered
Demonstrates understanding of lab values related to diagnosis
Seeks out instructor to report abnormal findings, & assistance
PROFESSIONAL ROLE BEHAVIOR
Demonstrates professional accountability
Completes nursing care in timely fashion
Medications and treatments administered correctly
Initiates and completes activities toward plan of care
INTEGRATION OF EVIDENCE BASED PRACTICE
Bases care on evidence based practice, knowledge and standards
Adapts care based on resident/patient outcomes/responses
CLINICAL DOCUMENTATION
Documents physical assessment
Documents therapeutic treatments and nursing care
Documents plan of care, responses, and adjustments made
Document instruction given to resident/patient/caregivers
110 Total points Clinical Evaluation (60% of total grade)
Deductions Clinical Evaluation
WRITTEN EVALUATION
Medication Cards
Identifies priorities for care
Clinical Reasoning Questions: Pre-Clinical
Clinical Reasoning Questions: Clinical
Clinical Reasoning Questions: Post-Clinical
25 Total Points Written Evaluation (40% of total grade)
Deductions Written Evaluation
DAY 3:
DAY4:
DAY 1
DAY 2
DAY 3
DAY 4
DAY 1
DAY 2
DAY 3
DAY 4
COMMENTS
Clinical Evaluation
N124L IN
Summer 2013
GRADING CRITERIA
5 = 100% - Always demonstrates this trait, critical thinking skills and behaviors. Performs tasks
independently and without prompting. Correctly completes paperwork
4 = 90-99% - Usually demonstrates this trait, critical thinking skills and behaviors, requires some assistance
with decision making.
3 = 80-89% - Often demonstrates this trait, more frequently needs reminders and prompting from instructor
or staff. Requires assistance with some critical thinking skills and decision making behaviors.
2 = 70-79% - Occasionally demonstrates this trait. Inconsistent performance requires ongoing assistance
and prompting, as well as supervision with tasks and critical thinking skills and behaviors.
1 = 60-69% - Unable to demonstrate this trait 50% of the time.
0 = <60% - Never demonstrates this train. made little to no effort for this clinical experience
CLINICAL
PERFORMANCE 60%
Day 1
Day 2
Day 3
Clinical Performance
Deductions:
 Does not provide
for patient privacy
-5 for each
occurrence
Critical Behaviors - unsafe
practice:
 In the event of documented
unsafe practices, the clinical
grade for the rotation will be
no greater than 76
 Documentation of a pattern
of unsafe practice will result
in the student's failure of this
course.
Day 4
Rotation
Average
Clinical
Performance
60% of
Grade
SCORE
DEDUCTIONS
CLINICAL TOTAL
WRITTEN
PERFORMANCE
40%
SCORE
DEDUCTIONS
Day 1
Day 2
Day 3
Day 4
Written
Performance
40% of
Grade
WRITTEN TOTAL
Point Deduction from Final Grade:
2 - Tardiness
9 - Absence
20 - Delayed notification of absence
Point Deduction from Daily Grade:
5 - Unprofessional dress
5 - Unprofessional behavior
5 - Unprepared for skill
Rotation Grade Deduction
Final Rotation Grade