Carly Legault

September 12, 2013

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 1
2nd Edition - Revised October 2008

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 2
2nd Edition - Revised October 2008

TABLE OF CONTENTS

SELF-ASSESSMENT TOOL - RATING SCALE..........................................................................4

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF PRACTICE.....................................4
A: Nursing Knowledge ...............................................................................................................4
B: Nursing Process..................................................................................................................... 5
C: Safety..................................................................................................................................... 5
D: Communication and Interpersonal Skills................................................................................5
W: Professionalism..................................................................................................................... 6
X: Nursing Practice and Leadership............................................................................................6
Self-Assessment Summary.......................................................................................................... 7
STEP 2: SELF-ASSESSMENT OF SPECIFIC COMPETENCIES..............................................8

STEP 3: LEARNING PLAN......................................................................................................10

RECORD OF PROFESSIONAL ACTIVITIES............................................................................11

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 3
2nd Edition - Revised October 2008

SELF-ASSESSMENT TOOL
The Self-Assessment Tool is used to assess your professional practice using the LPN Standards of
Practice and Competency Profile as a guide. Focus your assessment on your practice as a whole and
then those Specific Competencies which are directly related to your role and responsibilities.

RATING SCALE Use the following rating scale to complete your Self-Assessment.
1
Excellent

2
Competent

3
Requires
Improvement

4
Developmental

Demonstrates
excellence in the
expectations and /
or requirements of
the competency.

Meets the
expectations and /
or requirements of
the competency.

Has identified
weakness in
areas of
knowledge, skills,
attitudes, or
clinical judgment.

Requires
education and/or
orientation to
meet the
expectations and /
or requirements of
the competency.

5
Not Applicable
Not applicable to
current role and
responsibility.

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF

PRACTICE
Competency
Number

A: Nursing Knowledge

Year
2014

Year
20__

Year
20__

Year
20__

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

A-1

Applies knowledge of anatomy and physiology

of the human body to the assessment of client
and delivery of nursing care.

A-2

Applies knowledge of microbiology throughout

care, disease prevention, and health promotion.

A-3

Applies knowledge of pathophysiology to the

nursing care of the client.

A-4-4

Uses appropriate medical terminology to report

and document client care.

A-5-9

Adjusts nursing practice to the specific growth

and development of the client.

A-6

Applies principles of nutrition to the assessment

and care of the client.

A-7

Applies knowledge of pharmacology throughout

client care and teaching.

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 4
2nd Edition - Revised October 2008

Year
2014

Competency
Number

A-8-2

Integrates knowledge and skills from the

sciences and humanities into the application of
the nursing process.

B: Nursing Process

Rating
(1-5)

Performs health assessment of client using

assessment techniques and a systematic
process.

B-2-2

Implements the planning process and

establishes client priorities involving client in
planning.

B-2-3

Identify and analyze nursing diagnosis.

B-3

Implements nursing interventions to carry out

nursing care plan.

B-3-2

Reassess, review, and modify plan of care to

meet the needs of the client.

B-4

Evaluates the clients response to care and

treatment.

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

C-1 to
C-4

Applies critical thinking and clinical judgment

when responding to emergency situations.

C-5-1

Effectively uses protective devices to protect

client, self, and others.

C-6-1

Demonstrates the consistent application of

standard precautions.

C-7-1

Applies principles of medical and surgical

asepsis in the delivery of care.

C-12

Applies nursing knowledge and clinical

judgment to maintain physical safety of client.

1
Rating
(1-5)

D-1

Uses effective verbal and written

communication in the practice setting.

D-2

Appropriately establishes, maintains, and

closes the nurse-client relationship.

D-3

Collaborates with health care team to function

as an effective team member.

D-3-7

Adheres to the channels of communication

within the employing agency.

Self-Assessment Tool CCP

College of LPNs of Alberta

Year
20__

Rating
(1-5)

D: Communication and Interpersonal Skills

Year
20__

B-1

C: Safety

Year
20__

Page 5
2nd Edition - Revised October 2008

Year
2014

Competency
Number

D-4

Provides client and family teaching.

D-5

Reports and documents following legal

protocols, agency policy and procedure.

D-7

Applies clinical judgment in identifying problems

and resolving issues in client care.

D-8-1

Effectively manages time and organizes client

care to meet priority needs.

D-8-2

Demonstrates ability to rank the priority of client

needs.

W: Professionalism

Rating
(1-5)

W-1-3

Understands the key components of the Health

Professions Act-LPN Regulation.

W-2-3

Understands the Restricted Activity

authorizations in the LPN Regulation.

W-3

Understands the CLPNA Standards of Practice.

W-4

Adheres to the CLPNA Code of Ethics and

Standards of Practice.

W-4-5

Acts as an advocate for client and empowers

clients and families.

W-5-1

Demonstrates accountability for own nursing

practice.

W-6

Maintains the confidentiality of client

information.

W-7

Recognizes professional boundaries within the

nurse-client therapeutic relationship.

W-9

Accepts responsibility for continuing

competence and professional development.

W-9-4

Participates in continuous quality improvement

and evidence based changes to nursing
practice.

W-11

Keeps informed of current research affecting

health care delivery.

X: Nursing Practice and Leadership

Rating
(1-5)

X-1-5

Recognizes own strengths and limitations as a

leader.

X-3-5

Uses appropriate channels of communication to

report risks within setting.

Self-Assessment Tool CCP

College of LPNs of Alberta

Year
20__

Year
20__

Year
20__

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Page 6
2nd Edition - Revised October 2008

Year
2014

Competency
Number

X-4

Applies critical thinking and clinical judgment

when assessing or managing risk.

X-7-1

Shares knowledge, skill, and expertise with

colleagues and students.

X-7-3

Seeks opportunities to teach and mentor others.

X-7-4

Participates in committees, task forces and

professional activities to offer the LPN
perspective.

Year
20__

Year
20__

Year
20__

Year
20__

SELF-ASSESSMENT SUMMARY
Year

Competency
Number

2014

A-2
A-3
A-4-4
A-5-9
A-6
A-7
A-8-2
B-2-2

Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.

Applies knowledge of microbiology throughout care, disease prevention, and health

promotion.
Applies knowledge of pathophysiology to the nursing care of the client.
Uses appropriate medical terminology to report and document client care.
Adjusts nursing practice to the specific growth and development of the client.
Applies principles of nutrition to the assessment and care of the client.
Applies knowledge of pharmacology throughout client care and teaching.
Integrates knowledge and skills from the sciences and humanities into the application
of the nursing process.

C-6-1

Implements the planning process and establishes client priorities involving client in
planning.
Demonstrates the consistent application of standard precautions.

2014

D-4
D-7
D-8-1

Provides client and family teaching.

Applies clinical judgment in identifying problems and resolving issues in client care.
Effectively manages time and organizes client care to meet priority needs.

2014

W-1-3
W-4-5
W-7
W-9

Understands the key components of the Health Professions Act-LPN Regulation.

Acts as an advocate for client and empowers clients and families.
Recognizes professional boundaries within the nurse-client therapeutic relationship.
Accepts responsibility for continuing competence and professional development.

2014

X-1-5
X-4
X-7-1

Recognizes own strengths and limitations as a leader.

Applies critical thinking and clinical judgment when assessing or managing risk.
Shares knowledge, skill, and expertise with colleagues and students.

2014

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 7
2nd Edition - Revised October 2008

STEP 2: SELF-ASSESSMENT OF SPECIFIC COMPETENCIES

In this section, describe, assess, and rate the competencies specific to your area of work, specialty,
role and responsibility. Review the competency sections in the Competency Profile to guide your
assessment of the Specific Competencies. Seek feedback from another health professional.
Year

Competency
Number

G-4-1
2014

E-14-2

U-1-4

Rating
(1-5)

Describe & Assess Specific Competencies

Demonstrate knowledge and ability to receive post-operative

client from the recovery room
Assessed patients vital signs and CSM as per agency
policy after immediate return from recovery room
Demonstrate knowledge and ability to apply skin care / wound
management protocols according to agency policy.
Assessed stage 2 ulcer on patients coccyx on medicine
unit. Cleansed with normal saline, applied barrier cream
around wound and applied wound care dressing. Filled out
wound care form as per agency policy.

Demonstrate ability to adhere to agency policy and procedure in

the safe administration of medications.

2014

Performed up to 2 patient load pertaining to medication

administration during my medicine and surgical rotation at
the Royal Alexandra hospital

Performed 3 checks, demonstrated pharmacology knowledge and

included patient teaching

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 8
2nd Edition - Revised October 2008

STEP 3: LEARNING PLAN

This page is intended to document your Learning Plan for one year. Photocopy this BLANK page for each additional year.

Your Learning Plan must consist of at least TWO objectives for each year. You are required to fill out
all FOUR columns for each objective. Transfer your Learning Plan onto your Annual CLPNA
Registration Renewal Form. Please refer to the Guidelines at www.clpna.com for more information.

YEAR 2014
Learning Objectives

Resources & Strategies

Target Date

Evaluation

(What I am going to learn?)

(What will I do to meet

objectives?)

(Realistic time
frame for
achievement)

(How will I know I learned it?)

1) A-3-4
I will increase my
knowledge of the
pathophysiology related to
diabetes, specifically to the
complications related to
diabetes

____________________
2) A-4-4
I will increase my
knowledge of using the
appropriate medical
terminology in reporting
and documentation.

____________________
3) V-2-6
I will improve my
efficiency in calculating
infusion rates and
accurately setting the IV
pump.

I will review the

pathophysiology textbook
and YouTube videos in
regards to diabetes.
I will research medical
journals on the library
database that relates to
diabetic complications
presenting in patients.
_____________________
I will review the health
examination assessment
textbook as well as the
medical dictionary.

____________________
I will practice infusion
calculations on Edose (Safe
Medicate software) and on
the internet, as well as
attending open labs to use
IV pumps.

I will be able to describe

and educate a patient the
complications that are
associated with diabetes.
I will be able to answer
questions from the patient
accurately in regards to the
diabetes.

_____________
March 2, 2015
(By Next clinical
start date)

I will review examples of

documentation from lab
manuals and previous
clinical placements.

I will review my class notes,

lab exercises and textbooks
on how to accurately
calculate infusion rates.
Self-Assessment Tool CCP
College of LPNs of Alberta

March 2, 2015
(This is the start
of the next
clinical
placement)

_____________________
I will be able to use and
understand appropriate
medical terminology within
the 3 days of placement
while in report with the
interdisciplinary team, as
well as on documentation.
I will have reduced
questions for buddy nurse
about appropriate medical
terminology.

March 2, 2015
(By Next clinical
start date)

I will be able to efficiently

calculate infusion rates and
set up the IV smart pump
within 5 to 10 minutes.
I will have limited questions
for buddy nurse about
calculating infusion rate.

Page 9
2nd Edition - Revised October 2008

Name: Latasha Foster

CLPNA Registration #: ____________

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity
(include course,
seminar, research,
hours, details)

Sep 9, 2014 G56

Attendedabuddyshift
withawoundcarenurse
attheRoyalAlexandra
onmedicineunit51,
assistedbuddynurse
withwoundVAC
dressingonpatientsleft
sideofcoccyx.

Oct 2, 2014

1Hour
G-4-2
Observed and assisted
nurse on orthopedic
surgery at Royal
Alexandra to perform
initial post-operative
assessment and
procedures.

Name: Latasha Foster

Self-Assessment Tool CCP

College of LPNs of Alberta

Summary of Learning

I have learned that the wound-vac system draws the wound

edges together by evenly distributing negative pressure that
contracts the foam, which removes exudate and infectious
materials.

I have learned that assessing vital signs, performing CSMT

and head toe assessments, especially a neurovascular
assessment is critical to receiving a post-operative patient. I
have learned that by following post-operative protocols I
can potentially prevent/or identify the complications such as
DVT or PE in patients.

CLPNA Registration #:__________

Page 10
2nd Edition - Revised October 2008