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Evaluation Review

Preceptor Evaluation of Student


Date Completed:
Evaluation by:
Student evaluated:
Status:
54104
Evaluation Key:
1= Strongly disagree
2= Disagree
3= Neither agree/disagree or not applicable
4= Agree
5= Strongly agree

Question

Answe
r

I. Preparation of self
a. Exhibits appropriate
concern for patient and
family

b. Involves the patient


and family in the
assessment and
management of health
status

c. Responsible and
professional in manner,
appearance and clinical
practice

II. Interviewing skills


a. Skillfully observes the
patent and collects
history of current health
issues

b. Gathers appropriate
data for documentation
of the current health
issues

11/14/2014 4:02:00 PM
Hummer, Kristina
Jorgensen, Marylou

Comment

c. Collects a
comprehensive history of
previous health status as
related to current health
issues

d. Identifies psychosocial
status and other pertinent
information

III. Physical exam skills


a. Appropriately includes
specific physical exam
techniques for each
system or region related
to the presenting health
concern

b. Demonstrates special
techniques and exams as
related to the presenting
health concern

IV. Diagnostic reasoning


a. Able to include a
comprehensive recording
of the pertinent system
review to demonstrate
understanding of
differential diagnoses as
related to evidence based
research

b. Laboratory tests for


patient assessment are
appropriately obtained
and interpreted

V. Management plan
a. Plans appropriate care
for specific acute and
chronic health issues

b. Education and
counseling are specific for
presenting concern

c. Includes health
maintenance and
promotion in plan of care

d. Correctly prescribes
appropriate
pharmacologic
treatments

e. Identifies the need for


consultation in cases with
complex pathology

f. Includes follow-up care


for referrals, return
appointments and phone
calls

VI. Case presentation


a. Oral presentation is in
well organized format

b. Demonstrates evidence
based reasoning for
differential diagnoses of
presenting concern

VII. Documentation
a. Properly documents
history, physical exam,
evaluation and
management in format
consistent with clinical
site

b. Identifies appropriate
diagnostic codes and
billing levels

VIII. Initiative for selflearning


a. Demonstrates
advanced learning by
including evidence based
knowledge and standards
of practice

Additional comments:
For graduating students:
Does the preceptor feel
that the student is a safe
level beginning nurse
practitioner?
v2011

NA

One more semester

Evaluation Review
Preceptor Evaluation of Student
Date Completed:
Evaluation by:
Student evaluated:
Status:
52751
Evaluation Key:
1= Strongly disagree
2= Disagree
3= Neither agree/disagree or not applicable
4= Agree
5= Strongly agree

Question

Answe
r

I. Preparation of self
a. Exhibits appropriate
concern for patient and
family

b. Involves the patient


and family in the
assessment and
management of health
status

c. Responsible and
professional in manner,
appearance and clinical
practice

II. Interviewing skills


a. Skillfully observes the
patent and collects
history of current health
issues
b. Gathers appropriate
data for documentation

10/9/2014 2:15:00 PM
Jayasena, Rohan
Jorgensen, Marylou

Comment

of the current health


issues
c. Collects a
comprehensive history of
previous health status as
related to current health
issues

d. Identifies psychosocial
status and other pertinent
information

III. Physical exam skills


a. Appropriately includes
specific physical exam
techniques for each
system or region related
to the presenting health
concern

b. Demonstrates special
techniques and exams as
related to the presenting
health concern

IV. Diagnostic reasoning


a. Able to include a
comprehensive recording
of the pertinent system
review to demonstrate
understanding of
differential diagnoses as
related to evidence based
research

b. Laboratory tests for


patient assessment are
appropriately obtained
and interpreted

V. Management plan
a. Plans appropriate care
for specific acute and
chronic health issues

b. Education and
counseling are specific for
presenting concern

c. Includes health

maintenance and
promotion in plan of care
d. Correctly prescribes
appropriate
pharmacologic
treatments

e. Identifies the need for


consultation in cases with
complex pathology

f. Includes follow-up care


for referrals, return
appointments and phone
calls

VI. Case presentation


a. Oral presentation is in
well organized format

b. Demonstrates evidence
based reasoning for
differential diagnoses of
presenting concern

VII. Documentation
a. Properly documents
history, physical exam,
evaluation and
management in format
consistent with clinical
site

b. Identifies appropriate
diagnostic codes and
billing levels

VIII. Initiative for selflearning


a. Demonstrates
advanced learning by
including evidence based
knowledge and standards
of practice

Additional comments:
For graduating students:
Does the preceptor feel
that the student is a safe
level beginning nurse

NA

practitioner?
v2011

Evaluation Review
Preceptor Evaluation of Student
Date Completed:
Evaluation by:
Student evaluated:
Status:
55594
Evaluation Key:
1= Strongly disagree
2= Disagree
3= Neither agree/disagree or not applicable
4= Agree
5= Strongly agree

Question

Answe
r

I. Preparation of self
a. Exhibits appropriate
concern for patient and
family

b. Involves the patient


and family in the
assessment and
management of health
status

c. Responsible and
professional in manner,
appearance and clinical
practice

II. Interviewing skills


a. Skillfully observes the
patent and collects
history of current health
issues

12/2/2014 12:52:00 PM
Sheriff, Phyllis
Jorgensen, Marylou

Comment

b. Gathers appropriate
data for documentation
of the current health
issues

c. Collects a
comprehensive history of
previous health status as
related to current health
issues

d. Identifies psychosocial
status and other pertinent
information

III. Physical exam skills


a. Appropriately includes
specific physical exam
techniques for each
system or region related
to the presenting health
concern

b. Demonstrates special
techniques and exams as
related to the presenting
health concern

IV. Diagnostic reasoning


a. Able to include a
comprehensive recording
of the pertinent system
review to demonstrate
understanding of
differential diagnoses as
related to evidence based
research

b. Laboratory tests for


patient assessment are
appropriately obtained
and interpreted

V. Management plan
a. Plans appropriate care
for specific acute and
chronic health issues

b. Education and
counseling are specific for
presenting concern

c. Includes health
maintenance and
promotion in plan of care

d. Correctly prescribes
appropriate
pharmacologic
treatments

e. Identifies the need for


consultation in cases with
complex pathology

f. Includes follow-up care


for referrals, return
appointments and phone
calls

VI. Case presentation


a. Oral presentation is in
well organized format

b. Demonstrates evidence
based reasoning for
differential diagnoses of
presenting concern

VII. Documentation
a. Properly documents
history, physical exam,
evaluation and
management in format
consistent with clinical
site

b. Identifies appropriate
diagnostic codes and
billing levels

VIII. Initiative for selflearning


a. Demonstrates
advanced learning by
including evidence based
knowledge and standards
of practice
Additional comments:

For graduating students:


Does the preceptor feel
that the student is a safe
level beginning nurse
practitioner?

NA

v2011

Evaluation Review
Preceptor Evaluation of Student
Date Completed:
Evaluation by:
Student evaluated:
Status:
57267
Evaluation Key:
1= Strongly disagree
2= Disagree
3= Neither agree/disagree or not applicable
4= Agree
5= Strongly agree

Question

Answe
r

I. Preparation of self
a. Exhibits appropriate
concern for patient and
family

b. Involves the patient


and family in the
assessment and
management of health
status

c. Responsible and
professional in manner,
appearance and clinical
practice

II. Interviewing skills


a. Skillfully observes the

1/23/2015 8:05:00 AM
Kissi, Hamy
Jorgensen, Marylou

Comment

patent and collects


history of current health
issues
b. Gathers appropriate
data for documentation
of the current health
issues

c. Collects a
comprehensive history of
previous health status as
related to current health
issues

d. Identifies psychosocial
status and other pertinent
information

III. Physical exam skills


a. Appropriately includes
specific physical exam
techniques for each
system or region related
to the presenting health
concern

b. Demonstrates special
techniques and exams as
related to the presenting
health concern

IV. Diagnostic reasoning


a. Able to include a
comprehensive recording
of the pertinent system
review to demonstrate
understanding of
differential diagnoses as
related to evidence based
research

b. Laboratory tests for


patient assessment are
appropriately obtained
and interpreted

V. Management plan
a. Plans appropriate care
for specific acute and

chronic health issues


b. Education and
counseling are specific for
presenting concern

c. Includes health
maintenance and
promotion in plan of care

d. Correctly prescribes
appropriate
pharmacologic
treatments

e. Identifies the need for


consultation in cases with
complex pathology

f. Includes follow-up care


for referrals, return
appointments and phone
calls

VI. Case presentation


a. Oral presentation is in
well organized format

b. Demonstrates evidence
based reasoning for
differential diagnoses of
presenting concern

VII. Documentation
a. Properly documents
history, physical exam,
evaluation and
management in format
consistent with clinical
site

b. Identifies appropriate
diagnostic codes and
billing levels

VIII. Initiative for selflearning


a. Demonstrates
advanced learning by
including evidence based
knowledge and standards
of practice

personable, professional, ethical and sound fund of knowledge.


competent. needs work on differential diagnosis

Additional comments:
For graduating students:
Does the preceptor feel
that the student is a safe
level beginning nurse
practitioner?
v2011

Yes