Student Name: Jessica McElravey

Southwestern Oregon Community College Nursing Program

Nursing 112
Foundations of Nursing in Acute Care I

Clinical Evaluation Tool

The purpose of the weekly clinical performance evaluation tool is to provide feedback about achievement of the
course outcomes and competencies and to assist the student to meet the standards of care for nurses in Oregon as
outlined in the Nurse Practice Act.

Explanation of Rating Scale:

(S) Satisfactory = Clinical performance is safe and student adequately demonstrates application of the nursing
process/clinical judgment, required skills, and expected synthesis of learning appropriate to level in the program.
Verified by direct instructor observation.

(NI) Needs Improvement = Indicates that additional learning and attention to detail is required for a particular
item or that the overall performance for the week is at a minimum level. The instructor will write an explanation of
the rating on the comments page.

(U) Unsatisfactory = Clinical performance is unsafe and inadequately demonstrates application of the nursing
process/clinical judgment model, required skills, and expected synthesis of learning appropriate to level in the
program. The instructor will write an explanation of the rating on the comments page.

(NA) Not applicable = Particular item does not apply to the clinical performance.

(NO) Not observed = Instructor did not observe or has no knowledge of the students performance of the activity.

Students with a weekly grade of NI or U will be required to meet with their advisor and clinical instructor and
discuss a plan for change in their behavior before their next clinical experience.

Safety and legal/ethical concepts are considered critical to the profession and will be graded as NI or U if any
violation occurs.

If a student is assigned a U or NI for two weeks, the faculty will review the students clinical performance and
consider the options of either placing the student on probation or dismissing from the program.

In cases of potential failure, notification of the student by the instructor that she/he has been assigned a grade of U
or NI for one week constitutes proper warning of the grade status.

If a student is placed on probation and then receives a weekly grade of U, the faculty will review the students
performance and determine whether or not the student will be dismissed from the program.

2
Nursing 112 Clinical Evaluation Tool Student Name: Jessica McElravey

Clinical Week.
Midter Final
Competenc 2 3 4 5 m 6 7 8 9 10 Eval
QSEN y Eval
Competencie (C) 4/1 4/1 4/2 5/1 5/2 5/3
Dates 4/4
1 8 5
4/27 5/2 5/9
6 3 0
6/1
s Course
(KSA) Outcomes Attendance: P=Present, A=Absent, T=Tardy p p p p p P p
(O) MC MC LDR
Facility/Unit U
REU
U
REU PSU
P
REU

C9/O1, Applies concepts and theory to clinical practice

O2 in client care and written assignments:
1. Collects data and conducts a health s s s s s s s s s s
assessment on a client with an acute
condition.
2. Analyzes and interprets the data/assessment s s s
s s s s s s s
findings.
KSA: Patient Centered Care

3. Prioritizes health problems. s s s s s s s s s s

4. Develops a plan of care that considers the s s s
individual, family, age of client,
s s s s s s s
developmental stage, psycho-socio-cultural
issues, and/or learning needs.
5. Evaluates and reflects on plan of care. s s s s s s s s s s
C1/O3 Apply ANA Code of Ethics to care of patients s s s
s s s s s s s
with acute conditions/processes.
C6, C7, s s s
Recognizes cultural issues and interact with
C8/ s s s s s s s
clients in culturally sensitive ways
O1
C4/O4 Recognizes potential legal and ethical issues s s s
related to client autonomy across the lifespan s s s s s s s
in at risk populations.
C5/O3 Identifies roles and functions of members of the s
health care team involved in providing care for s s s s s s s s s
acute conditions/processes.
C8/O5 Uses therapeutic communication with patients s s s s s s s s s s
and agency staf
 QI, KSA: KSA: Teamwork & Collaboration

C10/O2 Uses research and evidence to support clinical s s s

s s s s s s s
decision making
Safety
EBP,

C6/O2 s s
PCC, QI KSA:

Utilizes resources as needed s s s s s s s s

Competenc
QSEN y
Midter
Competencie (C) Final
s Course
2 3 4 5 m 6 7 8 9 10 Eval
Eval
(KSA) Outcomes
(O)
C9/O2 s
Informatics, Professionalism KSA: Safety,

Demonstrate responsibility and accountability

for professional behavior: s s s s s s s s s
1. Performs safely in clinical.
C3/O 2. Prepared for clinical (Appropriate attire, s s s
appropriate tools such as stethoscope, skills s s s s s s s
list, evaluation tool, assessment tools).
C4 3. Takes initiative in making decisions and s s s
s s s s s s s
assuming responsibility for decisions.
C3 4. Looks for opportunities for continued s s s
s s s s s s s
learning and self-development.
C4 5. Identifies behaviors and attitudes s
s s s s s s s s s
influencing professional behavior.
C1, 6. Demonstrates growth in coping with s s s s s s s s s s
C2 stressful situations in a calm and
dependable manner.
 C8, 9 7. Documents accurately and thoroughly within the s s s
s s s s s s s
health record where applicable to clinical setting
C1/O 8. Maintains patient confidentiality. s s s
s s s s s s s
3
C3 9. Completes and submits assignments on s
s s s s s s s s s
time.
C2 10. Organizes and manages time efectively. s s s s s s s s s s
C4 11. Attends and participates at post- s s s
s s s s s s s
conference.
mj mj mj mjs mj mj mj mjs
Instructor Initials mjs mjs mjs
s s s s s s
Student Initials JM JM JM JM JM JM JM JM JM JM JM
Key: C=Competency, CO=Course Outcome, QSEN=Quality and Safety Education for Nurses, KSA=Knowledge, Skills & Attitudes (QSEN
Competencies)
 Instructor include comments that are positive, areas that need improvement or are unsatisfactory. Studen
Wee t
Reference the course outcomes listed in the syllabus, the OCNE Competencies from the Nursing Student
k Handbook and/or the QSEN competencies (Date/Sign all entries)
Initials

1st clinical this term. Original patient is discharged prior to start of shift and is very flexible when receiving new JM
2 patient assignment for the night. Very nice adaptation of care plan from previous patient to actual patient. Works well
with staf, classmates and patients, MSperry RNc
Cares for patient with chest tube and empyema dx- identifies communication issues when staf felt this was a typo JM
and stated patient had emphysemanice catch! Assessment documentation very well done and medication
interventions were appropriate for adverse reaction.
Nursing dx prioritized for disease process and reflections done on patient centered careRather than looking at
3 additional dependent interventions (medications, etc that may not be appropriate for patient) if goal is being partially
metlook at what nursing interventions helped and adapt your goal to what the patient is able to do Partially met
means you are on the right trackExcellent critical thinking today and nice communications MSperry RN

Cares for quadriplegic patient this week requiring PEG tube feedings and med administration. Able to do medication JM
admin through PEG using a stopcock device. Reviews policy prior to procedure and follows protocols. Assessment is
4 well documented and care plan is continuing to prioritize. Reflections are well thought through with critical thinking
and patient centered focus. Nice job MSperry RNc
Cares for cardiac pt this evening. Identifies top nursing dx and developing in prioritization of dx and interventions. JM
Assessment documentation is thorough and beginning to be used in dx and care planning. Adapts well to change of
5 pt due to discharge prior to clinical day. Flexible and patient centered. Nice communication skills and teamwork
tonight MSperry RNc
Midter Jessica has shown continued growth in assessment documentation, medication and labs collection and applying this JM
m
information to the nursing process. Good communication skills and teamwork MSperry RNc
Evaluati
on
3rd week that original patient discharged a beginning of shift. Able to adapt plans of care to new patient if appropriate JM
6 or to devise new Plan of care while taking care of patient. Diagnosis are continuing to grow and prioritize. Nice
communication skills and teamwork. MSperry RNc
JM
7 No Clinical

Cares for patient with multiple co-morbidities. Identifies primary dx and prioritizes care plans. Nice identification of JM
the Risk for bleeding with increased PTTS and decreasing platelets. Also identifying need for increased infection
protection d/t decreased WBC level. Dar is in correct format be sure to include all needed data and focus more on a
8 system issue rather than a medication administration. Med admin is documented in MAR/MAK. Professional and
therapeutic communication skills noted this week with staf, and patient. MSperry RN

Cares for stable mom and babe couplet this evening. Prioritizes care for both mom and baby with prioritized plans JM
and interventions. Nice teaching of parents and support. Witnesses birth (less than 45 min labor) with post-partum
9 hemorrhage. Identifies communication styles of clear calm statements to work with situation yet not alarm new
parents. Glad you had a good experience in LDRP MSperry RN
 Begins clinical as a load and Go gathering information, meds, labs and testing information on day of care. JM
Continues to improve in prioritization of care and interventions. Applies data appropriately and bases adaptations to
10 patients response. Excellent communication skills tonight with staf and identifying your role as a student nurse. It
has been a pleasure watching you grow through this term Melissa
Continues to grow with critical thinking and applying the nursing process this term. Prioritizes care well and works JM
Final
Eval
towards expected outcomes for patient. Growth in communication with staf, faculty and classmates as well as
conflict resolution. Meeting OCNE Benchmark Level 1
3/07/17: sw
5