Final Clinical Evaluation

NUR 4216L BMC SBN 010 2/25/2014

Evaluation date: 4/16/2014
Evaluator: Harding, Deb (dharding@health.usf.edu)
Evaluatee: Dean, Chelsea (cdean2@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. 2Unsatisfactory 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 nursepatient 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: 3
Minimal
Comment: Ms. Dean will be able to do this in her preceptorship.
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
(Comment
Answer: 5
Outstanding: Exceeds Standards
Required)
Comment: Exceptionally respectful of staff, patients, and this instructor.
Standard I-Attitude The student is actively engaged in and seeks out opportunities for
learning.
(Comment
Answer: 5
Outstanding: Exceeds Standards
Required)
Comment: Very enthusiastic in seeking learning opportunities.
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: Under the supervision of her preceptor.
Standard II-Safety The student implements orders accurately and efficiently.
Answer: 4
Satisfactory: Meets Standards
Comment: Same as above.
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 decisionmaking 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.
(Comment
Answer: 5
Outstanding: Exceeds Standards
Required)
Comment: Ms. Dean displays above average thought process on disease, labs, and
medications as well as the implementations involved.
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: 3
Minimal
Comment: There is not much chance to do this implementation. It is discussed in post
conference.
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:
Ms. Dean you have grown so much in your critical thinking skills and patient assessment skills.
You are able to see what is going on with a patient based upon disease process and have great
insight on the psychosocial aspect of nursing. You are very professional in actions and
appearance, and you display above average advancement through this clinical.209. D. Harding,
MS, RN