Anum Bhojani

Carly Legault
September 12, 2013

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
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
2015_
_

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.

Year
2015_
_

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__

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)

2
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.

D: Communication and Interpersonal Skills

Year
20_

B-1

C: Safety

Year
20__

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.

Year
2015_
_

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.

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)

Year
2015_
_

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
2015___

Competency
Number

Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
A
A-3
A-2
A-5-9
A-7
A-8-2
B
B-2-3
B-3
B-3-2
B-4

Nursing knowledge

Nursing process

C
C-1 to
C-4
C-5-1
C-6-1
C-7-1
C-12

Safety

D
D-1
D-2
D-3
D-3-7
D-7
D-8-1
D-8-2

Communication and
interpersonal skills

W
W-1-3
W-2-3
W-3
W-4
W-5-1
W-9-4
W-11

Professionalism

Nursing practice and

X
X-4
X-7-4

leadership

20___

20___

20___

20___

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

2015

Competency Number

G: Surgical
G-3: Endoscopy
G-3-7

Describe & Assess Specific Competencies

Rating
(1-5)

Demonstrate knowledge and ability to assist with/perform various

procedures associated with therapeutic and diagnostic endoscopy
according to agency policy including:
upper/lower gastrointestinal procedures
pulmonary procedures
stabilize scope for the purpose of visualization
manage inflation/deflation of dilation device as directed

 submucosal/intramural injection or tattoo-marking medication(s) as

directed
manipulate biopsy and retrieval equipment to obtain specimen as
directed
manipulate clip device to open, close and release as directed
prepare cautery equipment for use
prepare Hemospray device and deliver Hemospray dose as directed
assist physician with preparation of banding device
prepare and label specimens
E: Nursing
Practice
E-16: Postmortem care
E-16-5

20___

20___

20___

20___

Demonstrate knowledge and ability to assist in post mortem

examination and sample procurement.

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 2015
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?)

Demonstrate knowledge
and ability to perform or
assist with upper and
lower GI procedures and
pulmonary procedures.

Demonstrate knowledge
to assist and postmortem examination

Name: Anum Bhojani

Read the
procedure
guideline in Potter
& Perry.
Ask a fellow
nurse/mentor/
preceptor to walk
me through the
procedure the very
first time.
Observe procedure
before performing
it.

April 30th,
2016

Observe a fellow
nurse/preceptor/m
entor before
assisting.
Read Potter &
Perry to learn the
procedure
Practice the
procedure before
to make sure I
understand it

April 30th, 2016

Feedback from a
fellow
nurse/preceptor/m
entor.
Repeat the
procedure on my
own at least twice
without assistance.

Feedback from a
fellow
nurse/preceptor/m
entor.
Perform it more
than once without
assistance

CLPNA Registration #: ____________

RECORD OF PROFESSIONAL ACTIVITIES

Date

May 2015

May 2015

September
2015

October 2015

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

Summary of Learning

Diet and Nutrition

Seminar
1 hour

NPRT 1001
145 hours
Devonshire Care Centre

Learned about different types of diets for seniors.

Dysphagia
Thicken fluids
Discussed meal portions and nutritional needs for
geriatric patients.
Patient research
Client centered care for up to two patients
Medication administration
Head to toe assessments
Documentation
Assisted clients with ADLs
Lift and transfers

NPRT 2101
145 hours
Medicine
University of Alberta
Hospital

Patient research
Client centered care for up to two patients
Medication administration
Catheter insertion/care/irrigation
Head to toe assessments
Documentation
Client teaching
Wound care
Client teaching

NPRT 2102
145 hours
Orthopedic surgery
University of Alberta
Hospital

Patient research
Client centered care for up to two patients
Medication administration
Head to toe assessments
Post/pre op care
Documentation
Client teaching
Dressing changes
Catheter care/insertion/irrigation
Oxygen therapy
Removal of sutures/staples
Client teaching
Learned about different types of hard wares used in
orthopedic surgery.

Name: Anum Bhojani

CLPNA Registration #:__________