Final Clinical Evaluation

NUR 4467L BMC SBN 10/23/2014

Evaluation date: 11/18/2014
Evaluator: Lash, Jenni (jennilynn.lash@hma.com)
Evaluatee: Clark, Jaleesa (jclark13@health.usf.edu)

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 The student communicates pertinent information regarding the
patient's condition/concern to health team members.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication The student communicates effectively in written form (Nursing
Process Worksheet is organized and complete)
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication The student communicates effectively in verbal form.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication The student initiates, maintains, and terminates the nurse-patient
relationship using principles of therapeutic communication.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication The student functions as an advocate for the patient/family and
communicates family needs to other members of the health care team.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication The student examines the dynamic interactions between the patient,
family, community, and society.
Answer: 4
Satisfactory: Meets Standards
Comment:

Standard I--Communication The student initiates discussion to identify and resolve interpersonal
problems that impact care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication The student uses interpersonal skills to enhance patient/family
coping abilities.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication The student discusses the ethical issues and approaches the ethical
dilemmas that confront the patient/family and appropriately discusses experience with
faculty/preceptor.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication The student delegates appropriately to patient care technician, family,
or other team members.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I-Knowledge The student applies knowledge of humanities, physical and social
sciences, and nursing when providing patient care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I-Knowledge The student applies knowledge of social, cultural, and genetic factors to
the care of diverse populations.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I-Attitude The student does not in anyway demonstrate disrespect or inappropriate
behavior to the patient, staff, or faculty
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I-Attitude The student is actively engaged in and seeks out opportunities for learning.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety The student does not make judgmental, discriminatory, or prejudicial
statements to the patient, staff, or faculty.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety The student applies principals of universal precautions, practices specific
isolation techniques, and teaches the reasons for universal precautions.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety The student assesses patients for fall risk and applies principles of safe patient
handling.
Answer: 4
Satisfactory: Meets Standards
Comment:

Standard II-Safety The student maintains the patient's physical safety by protecting the patient
from harm.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety The student maintains medical and surgical asepsis when doing procedures
requiring sterile technique.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety The student properly identifies techniques and teaches the reasons for
universal precautions.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety The student validates the accuracy and appropriateness of orders for
nursing/medical care prior to initiating care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety The student implements orders accurately and efficiently.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety The student 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.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety The student adapts skill performance using principles of theory when
necessary.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Assessment The student identifies data from the history and
physical assessment to formulate appropriate nursing diagnoses.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Assessment The student identifies the patient's health education
needs.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Diagnosis The student synthesizes history and assessment data as
well as diagnostic results into the development of nursing diagnoses.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Plan The student integrates psychosocial needs into care plan,
identifies appropriate resources for the plan of care, and incorporates health education into the
care plan.
Answer: 4
Satisfactory: Meets Standards
Comment:

Standard III-Nursing Process:Plan The student identifies measurable, expected patient outcomes
that are realistic and individualized to the patient.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Plan The student identifies the discharge planning process and
needs of the patient upon admission and throughout the hospitalization.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Plan The student demonstrates judgement in decision-making and
priority setting.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Plan The student uses appropriate collaborative resources to
personalize the nursing care the patient receives.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation The student demonstrates
understanding of the principles underlying nursing actions appropriate for the student at this
point in the curriculum.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation The student performs skills according
to agency policy and procedure and clinical lab guidelines.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation The student implements the written
action plan/protocol considering the priorities for each assigned patient.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation The student implements a teaching plan
based on scientific knowledge and utilizes resources appropriately.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation The student incorporates evidence
based research into nursing practice.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation The student practices individualized
and culturally competent care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation The student initiates appropriate
referrals as needed.
Answer: 4
Satisfactory: Meets Standards
Comment:

Standard III-Nursing Process:Evaluation The student evaluates the patient's response/outcome to

the intervention.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Evaluation The student utilizes subjective and objective data to
revise nursing actions (as appropriate for the student at that level of the curriculum).
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Organization The student provides organized, coordinated, and
prioritized nursing care for the patients with a range of health problems.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Organization The student organizes time and resources effectively
and efficiently.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Organization The student gathers and organizes equipment
necessary for patient care/procedures.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Organization The student identifies and seeks appropriate resources
during patient care provision.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Organization The student completes the daily clinical assignment in
a timely manner.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Documentation The student appropriately develops long and short
term patient oriented nursing care goals based on patient assessment and scientific principles of
nursing practice.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Documentation The student documents problems and nursing care
goals in the patient record (with co-signature).
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Documentation The student identifies and documents nursing
actions/orders initiated in implementing the plan of care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Documentation The student correctly enters data into the patient
record in a timely manner per agency protocol.
Answer: 4
Satisfactory: Meets Standards
Comment:

Standard III-Nursing Process:Documentation The student assures privacy of the patient record at
all times.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Critical Thinking The student utilizes critical thinking skills to
prioritize patient needs based on the patient assessment.
Answer: 4
Satisfactory: Meets Standards
Comment:

Comments:
Very excited to be part of this rotation. Genuine Interest in this field of nursing. She is completing her last
days with a preceptorship on L&D and we couldn't be happier with her growth! Exceptional with patients,
families, and staff.