PERFORMANCE APPRAISAL FOR

REGISTERED NURSE
Employee Name:
Date:
Evaluator's Name:
Title:
For each area of performance evaluate the level of achievement demonstrated
during the past year.
AREAS OF PERFORMANCE
Autonomy and Accountability
Patient Care Management
Professionalism
LEVEL OF ACHIEVEMENT
5 - Outstanding
4 - Highly Effective
3 - Effective
2 - Improvement Needed
1 - Unacceptable
NA- Not Applicable
Areas of Performance

Level of Achievement

A. Autonomy and Accountability

1. Functions within legal framework
of the Nurse Practice Act of the state
currently employed

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2. Performs work assignment with minimum

need for supervision and guidance.

3. Demonstrates reliability in meeting

deadlines and completing
responsibilities.

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4. Possesses skills and technical

competence to execute work
responsibilities.
-------------5. Demonstrates responsibility and
reliability in meeting scheduled

Areas of Performance

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Level of Achievement

6. Operates within the established

company guidelines

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7. Complies with hospital policies

and procedures.

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8. Assists with training/education of

staff, contributes to an open learning
environment.

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9. Displays ability to utilize appropriate

channel(s) for communication and/or
problem solving.

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10. Adheres to Hospital and Company

health and safety standards.

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B. Patient Care Management

1. Utilizes established Nursing
Department Standards in the
delivery of patient care.

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2. Utilizes clinical knowledge and skills

to assess the needs of assigned
patients.

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3. Completes and documents initial and

ongoing assessments as per policy.
Written communication is clear, legible
and objective.

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4. Prioritizes care based on medical and

nursing diagnosis, nursing history, DRG
and expected patient outcomes.

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5. Demonstrates ability to set goals, assign

priorities, anticipate problems, establish
limits and achieve quality results.

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6. Completes tasks with timeliness,

schedules and uses time efficiently.

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7. Develops comprehensive plan of care

from admission to discharge for
assigned patients based on patient
needs, standards of care, DRG and
expected patient outcomes.

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Areas of Performance
8. Functions as a patient advocate
assuring patient's right to information,
providing patient safety at all times, and

Level of Achievement
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maintaining confidentiality.
C. Professionalism
1. Promotes good public relations for
CCMS and Hospital.
2. Communicates accurately/appropriately
with patients, family and other personnel.
Establishes and maintains therapeutic
and supportive relationship.

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3. Adheres to Company/Hospital dress

code policy.

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4. Reports to work in a timely manner.

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5. Effectively expresses self. Listens

attentively and creates a climate of open
communication. Respects confidentiality
and privacy.
6. Accepts constructive comments from
hospital/contracting company as a
mechanism for improvement.
7. Maintains credentials and education
files as per JCAHO standards and
Department of Health Regulations.
8. Functions as an integral part of the
health care delivery team and participates
in the maintenance of a cohesive work
environment.
Signature of Clinical Nurse
Date

__________

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Signature of Branch/ Nurse

Manager : --------------------------- Date:
Signature of Division Officer/Designee:----------------------------Date
COMMENTS: Areas of performance marked Level 1 or Level 2 must be
accompanied by comments.