Xyz Clinical Evaluation Tool-Yastrzemski 1

XYZ School Clinical Evaluation tool
Clinical Performance Evaluation Tool
Student Name
Rose Breen
Faculty Name Semester Fall 2017

Dara Yastrzemski
Student must obtain a 3 (75%) and a yes (Y) in all competencies at the final evaluation for the course.
Core Competencies Score

Students will begin to develop critical thinking abilities utilizing the nursing process in the roles of communicator and
caregiver. Students will learn principles of professional nursing practice and provide direct care to individuals in a
variety of settings while recognizing the diverse uniqueness of individuals with health alterations.
I. Patient-Centered Care
a. Begin to develop an individualized plan of care with a focus on assessment and planning utilizing the 2
nursing process. Begin to Interpret and utilize patient assessment data to modify patient care.
b. Demonstrate caring behaviors. Communicate effectively with client. 3
c. Conduct a basic assessment while eliciting patient values, preferences, needs, with respect for diversity. 2
d. Deliver care based on beginning knowledge of pathophysiology with respect for individual values, 2
preferences, needs, and diversity.
e. Assess the presence and extent of pain and suffering. 2
f. Demonstrate beginning competency in skills. 1
II. Teamwork and Collaboration
a. Develop effective communication skills with all appropriate members of the healthcare team 1
b. Begin to develop collaboration skills in working with the inter-disciplinary team members to address 1
client care needs
c. Participate in pre and post conferences to identify patient needs and methods to deliver care more 2
effectively for the next interaction.
d. Demonstrate awareness of own strengths and limitations as a team member. 2
e. Initiate requests for help when appropriate to situation. 1
III. Evidence-Based Practice
a. Begin to understand the concept of evidence-based practice in determining best clinical practice 2
b. Begins to utilize evidenced-based resources for clinical learning and practice 1
IV. Quality Improvement
Begin to deliver care in a timely and efficient manner. 1
Begin to identify areas and information in the health care setting about processes/projects to improve care 2
(QI).
Begin to understand the importance of variance reporting in how it impacts patient care protocols and risk 2
prevention. For example: Fall Risk
V. Safety
a. Integrate effective use of technology and standardized practices that support safety. 2
b. Implement strategies to reduce risk of harm to self or others. 1
c. Begin to recognize and report abnormal findings 1
d. Recognize and adhere to national patient safety guidelines that affect outcomes for patients and families. 2
e. Perform clinical procedures demonstrating appropriate knowledge and skill. 1
*Content based upon QSEN Competencies and KSAs.

Developed 6/2016
f. Examine the healthcare environment to determine patient and family safety needs 1
g. Develop the awareness of the impact of unsafe practices by self and others and communicate findings to 1
appropriate healthcare providers.
h. Organize client care in a timely, effective, and safe manner
VI. Informatics
a. Navigate the patient written/electronic health record to plan patient care and monitor changes in patient 2
status.
b. Begin to document clear and concise responses to care in the patient written/electronic health record as 2
appropriate to the clinical setting.
c. Manage data, information, and knowledge of technology in an ethical manner. Protect confidentiality of 2
electronic health records.
VII. Professionalism
a. Recognize and begin to demonstrate core professional values (caring, altruism, autonomy, integrity, 2
human dignity, and social justice).
b. Maintain professional behavior and appearance. 2
c. Provide evidence of preparation for clinical learning experiences. 2

d. Comply with the Code of Ethics, Standards of Practice, and policies and procedures of XYZ University, 2
School of Nursing and clinical agencies.
e. Accept constructive criticism and participate in plan of action for improvement. 2
f. Maintain a professional attitude when interacting with inter-disciplinary team members, faculty, and 2
fellow students.
g. Arrive to clinical experiences at assigned times. 3
h. Demonstrate professional behaviors 2
i. Accept individual responsibility and accountability for nursing interventions, outcomes, and other 2
actions.
j. Engage in constructive self-evaluation. 2
k. Assume responsibility for learning. 2
TOTAL SCORE ( of 128 points possible) 66
*See clinical evaluation tool guidelines for full descriptions of grades 1-4
(Exemplar must include correlating core numbers I-VII and knowledge, skills, and attitude letter (KSA))
4-exceeds expectations 3-meets expectations 2-below expectations 1-does not meet expectations
Faculty Comments:
The factors that have led me to grade your performance as below expectations have been demonstrated by your poor
communication skills, lack of progress in your clinical skills, and your inability to prioritize patient care.
Communication encompasses both verbal and written skills with patients, faculty, and staff nurses. It has been noted
that you have a difficult time initiating conversation and because of this, have put the patient in potential risk by failing
to report critical lab values in a timely manner. You did give the information to me in post-conference, admitting you
weren't sure if the level was abnormal.
You have demonstrated that you are empathic and have a caring attitude with your patients. It has been noted that you
lack the ability to perform certain skills and plan/organize your care. I have worked with you to help in planning and

Developed 6/2016
organizing your day, but you still need guidance and have not shown growth in this area.
Although you have acknowledged this as a weakness, you have not been able to progress and therefore are not meeting
all the objectives of the course. Your class work has been passing, but you are unable to connect your curricular
outcomes and theory content with your clinical experience. It is understandable that learning takes time and it is my
recommendation that you are given a contract with remediations, such as additional lab time, testing, and papers. If all
of these can be passed successfully, and you can demonstrate these skills in clinical, you may be reevaluated.
* Please note there is usually a signature page for faculty in addition to student comments and signature

Developed 6/2016

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XYZ School Clinical Evaluation tool

Clinical Performance Evaluation Tool

Faculty Name Semester Fall 2017

Core Competencies Score

*Content based upon QSEN Competencies and KSAs.

c. Provide evidence of preparation for clinical learning experiences. 2

*Content based upon QSEN Competencies and KSAs.

*Content based upon QSEN Competencies and KSAs.

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