Carroll Community College

Department of Nursing
NURS 242 Nursing Concepts 4
Student Clinical Performance Evaluation SUMMATIVE
Student

Jill Hull

Date

Practicum

Location Carroll
Hospice

Faculty

N/A = Not
(*) Critical behavior
applicable
Students who meet any of the following criteria will be given a remediation plan and may be placed on probation.
Failure to progress in these areas may result in failure of the course.
-One unsatisfactory grade in a critical behavior
-Two needs improvements in a critical behavior
-Two unsatisfactory grades in a non-critical behavior
-Four needs improvements
Student Instructor
Outcome 1
SelfEval of
Evaluate the effectiveness of a plan of care using the nursing process to achieve patient
Eval
Student
outcomes.
S/N/U
S/N/U
Collects evidence related to assigned patient(s) from appropriate resources.
S
S
*Demonstrates accurate patient assessment skills.
S
S
Establishes nursing diagnoses based on patient assessment.
S
S
*Prioritizes patient care based on assessment.
S
S
Identifies measurable patient outcome based on nursing diagnosis.
S
S
Implements care according to established plan and desired outcomes.
Uses therapeutic communication techniques during nurse/patient interactions to facilitate the
S
S
nursing process.
*Identifies appropriate interventions based on assessment.
S
S
S
S
*Demonstrates knowledge of medications for assigned patients.
S
S
*Administers medication safely using six rights of medication administration.
S
S
*Implements appropriate infection control precautions.
S
S
Follows through with all patient care.
*Evaluates patient response to care and revises plan as needed.
S
S
Student Instructor
Outcome 2
SelfEval of
Assimilate into the profession of nursing with a commitment to lifelong learning and personal and
Eval
Student
professional growth.
S/N/U
S/N/U
S
Participates actively in all aspects of the clinical experience.
S
S
Discusses patients plan of care with instructor.
S
S
Demonstrates professional behavior and appearance.
S
S
Engages in self-reflection and communicates learning needs to instructor/preceptor.
S
S
Completes assignments as required and submits on time.
S
S
Organizes time efficiently.
S
Student Instructor
Outcome 3
SelfEval of
Provide culturally competent, holistic care using respectful and caring behaviors.
Eval
Student
S/N/U
S/N/U
Demonstrates caring behaviors with the ability to develop and maintain therapeutic relationships
S
with people from diverse backgrounds.
S
Considers patient values, cultural characteristics and religious differences when planning care.
S
S
Student Instructor
Outcome 4
SelfEval of
Collaborate with healthcare teams to provide patient-centered care.
Eval
Student
S/N/U
S/N/U
S
Identifies patient/family health education needs.
S
S
Implements patient and family education.
S
S
Seeks input from patient, instructor, peers, and healthcare team in the delivery of patient care.
S
S = Satisfactory

N = Needs Improvement

Approved 12/41/4. Revised 12/9/2014

U = Unsatisfactory

Carroll Community College

Department of Nursing
NURS 242 Nursing Concepts 4
Student Clinical Performance Evaluation SUMMATIVE
*Updates instructor and healthcare team regarding changes in the patients condition.
*Identifies safety concerns and notifies instructor and appropriate healthcare team members.
Demonstrates initiative in assisting peers and healthcare team members in the clinical setting.
Demonstrates communication skills using SBAR.
Acts as an advocate for patients and families.
Outcome 5
Model a spirit of inquiry that supports evidenced-based practice.
Applies evidenced-based rationale that supports the patients plan of care.
Integrates knowledge from nursing and other disciplines to plan care.
Outcome 6
Practice within legal and ethical principles to deliver safe and competent care based on current
standards of practice.
Adheres to attendance policy.
*Demonstrates safe clinical practice.
*Provides nursing care based on the policies and procedures of the facility.
*Maintains legal accountability for nursing practice in accordance with the Maryland Nurse
Practice Act.
*Adheres to HIPAA guidelines regarding patient confidentiality.
*Provides care according to the ANA Nursing Scope and Standards of Practice.
*Demonstrates accountability and responsibility for own actions and attitudes.

S
S
S
S
S
Student
SelfEval
S/N/U
S
S
Student
SelfEval
S/N/U
S
S
S

S
S
S
S
S
Instructor
Eval of
Student
S/N/U

S
S
Instructor
Eval of
Student
S/N/U

S
S
S

S
S
S
S
S
S
S
S
Student Instructor
Outcome 7
SelfEval of
Research and communicate information through appropriate technology.
Eval
Student
S/N/U
S/N/U
Gathers data from the electronic medical record to provide patient care.
S
S
Uses electronic medical record to document patient care accurately and in a timely manner.
S
S
Student Learning Goals (List desired learning goals, and your plans to meet them, for the next weeks clinical
experience. Goals should be based on identified performance issues and the desire for new knowledge and
experiences.)
I was fortunate enough to experience hospice care during my practicum. My goal was to be more confident in my
assessment skills and I was able to do that with this experience with frequent assessments. I was also able to become
more familiar with hospice care and what identifies a hospice patient. I became more confident in medication
administration and trach care. I would definitely say this was a good learning experience and would be interested in
becoming a hospice nurse in the future.

Preceptor/Instructor comments/ Student Learning Goals: (**If an item was identified as N or U, narrative
comments are necessary to clarify student performance**)

Jill was a pleasure to have at the Dove house. She exhibited her knowledge and
compassion with all patients and family members with a calm and respectful manner. I
would gladly work with her as a fellow staff member.
Approved 12/41/4. Revised 12/9/2014

Carroll Community College

Department of Nursing
NURS 242 Nursing Concepts 4
Student Clinical Performance Evaluation SUMMATIVE

Date:
10/26/15

Student Signature: Jill Hull

Preceptor/Instructor Signature:

Approved 12/41/4. Revised 12/9/2014

Samantha Thilker, RN BSN

CHPN

Date:

10/24/15