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2nd Edition - Revised October 2008
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2nd Edition - Revised October 2008
TABLE OF CONTENTS
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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.
A: Nursing Knowledge
Year
2016
Year
201__
Year
20__
Year
20__
Year
20__
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
A-1
A-2
A-3
A-4-4
A-5-9
A-6
A-7
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2nd Edition - Revised October 2008
Year
2016
Competency
Number
A-8-2
B: Nursing Process
Rating
(1-5)
B-2-2
B-2-3
B-3
B-3-2
B-4
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
C-5-1
C-6-1
C-7-1
C-12
1
Rating
(1-5)
D-1
D-2
D-3
D-3-7
Year
20__
Rating
(1-5)
Year
20__
B-1
C: Safety
Year
201__
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2nd Edition - Revised October 2008
Year
2016
Competency
Number
D-4
D-5
D-7
D-8-1
D-8-2
W: Professionalism
Rating
(1-5)
W-1-3
W-2-3
W-3
W-4
W-4-5
W-5-1
W-6
W-7
W-9
W-9-4
W-11
Rating
(1-5)
X-1-5
X-3-5
Year
201__
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)
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Year
2016
Competency
Number
X-4
X-7-1
X-7-3
X-7-4
Year
201__
Year
20__
Year
20__
Year
20__
SELF-ASSESSMENT SUMMARY
Year
20_16_
Competency
Number
C-1 to
C-4
x-7-4
Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
20_16_
x-4
20__16_
20___
20___
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Competency
Number
20_16_
C-1 to C4
20__16_
X-7-4
20___16
D-8-1
Rating
(1-5)
20___
20___
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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 2016
Learning Objectives
Target Date
Evaluation
(Realistic time
frame for
achievement)
1) June 2016
2) August 2016
1) -When my patients
come back from surgery I
will be able to apply the
knowledge I have learnt
throughout my research to
ensure they do not have
any post-operative
complications.
-When our unit gets
audited on handwashing
we will get a top mark
2) I will know Ive learned
more about myself by
constantly reflecting and
by understand where I
have gone wrong and how
I am able to improve these
areas
- I will also confide in
nurses around me and ask
how they find my
progress coming along.
1) knowledge of
microbiology
throughout care,
disease
prevention and
health promotion,
by reading and
reviewing my
pathophysiology
textbook.
2) Recognize personal
strengths and
limitations in myself
by constantly
reflecting.
Name: ___________________________
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Professional Activity
(include course,
seminar, research,
hours, details)
Summary of Learning
CPR certification
March
11,2015
2,05,201529,05,2015
February
2015
Name: _____________________
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2nd Edition - Revised October 2008