Amandeep Kaur

Cindy Home
January 23, 2017

TABLE OF CONTENTS
SELF-ASSESSMENT TOOL - RATING SCALE..........................................................................
STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF PRACTICE.....................................
A: Nursing Knowledge ...............................................................................................................
B: Nursing Process.....................................................................................................................
C: Safety.....................................................................................................................................
D: Communication and Interpersonal Skills................................................................................
W: Professionalism.....................................................................................................................
X: Nursing Practice and Leadership............................................................................................
Self-Assessment Summary..........................................................................................................

STEP 2: SELF-ASSESSMENT OF SPECIFIC COMPETENCIES..............................................

STEP 3: LEARNING PLAN......................................................................................................

RECORD OF PROFESSIONAL ACTIVITIES............................................................................

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
Assessment.

Use the following rating scale to complete your Self-

1
Excellent

2
Competent

3
Requires
Improvement

4
Developmental

5
Not Applicable

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.

Not applicable to
current role and
responsibility.

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF

PRACTICE
Competency
Number

A: Nursing Knowledge

Year
2017_

Year
20__

Year
20__

Year
20__

Rating

Rating

Rating

Rating

(1-5)

(1-5)

(1-5)

(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.

A-8-2

Integrates knowledge and skills from the

sciences and humanities into the application of

the nursing process.

B: Nursing Process

Rating

Rating

Rating

Rating

(1-5)

(1-5)

(1-5)

(1-5)

Rating

Rating

Rating

Rating

(1-5)

(1-5)

(1-5)

(1-5)

Rating

Rating

Rating

Rating

(1-5)

(1-5)

(1-5)

(1-5)

B-1

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.

C: Safety
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

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.

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

Rating

Rating

Rating

(1-5)

(1-5)

(1-5)

(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

Rating

Rating

Rating

(1-5)

(1-5)

(1-5)

(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.

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.

SELF-ASSESSMENT SUMMARY
Year

Competency

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

Number

20_17_

A-1
A-2
A-3
A-4-4
A-5-9
A-6
A-7
A-8-2

Nursing Knowledge

20_17_
_

20_17_
_

20_17_

2017__
_

201
7

B-1
B-2-2
B-3
B-3-2
B-4

Nursing Process

C-1 TOC4
C-5-1
C-6-1
C-7-1
C-12

Safety

D-1
D-2
D-3
D-3-7
D-4
D-5
D-7
D-8-1
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
X-1-5
X-4
X-7-1
X-7-3
X-7-4

Communication and Interpersonal Skills

Professionalism

Nursing Practice and Leadership

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

Competenc

Describe & Assess Specific Competencies

y Number

D-8-1

Rating
(1-5)

Effective time management and organizes plan of care to

2017__

meet priority needs. This is my vital learning need because if

I

am not good to utilize my time properly I will not be able to

complete my work for my shift, which would lead to creat more
work for me and other for my co-workers. Sometimes have to
face conflict issues and patient will also suffer if they don't get
their needs according to their requirements. As a result, it
could
cause harm for my patients, because I might not able to do
my
complete client care if I dont organize my time well
B-3
2017_

Implement nursing interventions to work according to the

nursing care plan. If I don't know to how use the nursing care
plans for my patients, then it will be hard for me to be able to
assess and apply my knowelege as per their needs.

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 2016

Learning Objectives
(What I am going to
learn?)

1.Effective time
management and
organize client care to
meet client's priority
needs.

Resources & Strategies

(What will I do to meet objectives?)

1.By using my learning stratgies and

ask
coworkers/peers for suggestions to
use
time effectively.
2.After my shift I will reflect how I
managed my time well and how I

Target Date
(Realistic
time frame
for
achievement)
Hopefully I will
accomplish
this learning
outcome is
June2017

Evalua
(How will
learned

I will evaluate

when I will be

complete my
planned and

effectively I o
the

work on prio
organized my work to prioritized my
client's needs.

would only be
successful

if I will be no
feel

rushed and I
to
complete all
tasks..

2.I will be able to use

1.Review the books for care plan's

I will get this

When I feel c

my knowledge how to

steps

skill in May

organize all t

2017- end of

and activities

June 2017

my patients n

set the goals of care

plan on priority the

2. I will book open lab to practice on

basis

the scenarios, follwing steps which

according to

need comes first.

requirements

3.will get good exposure while caring

patients in real setting during my
clinicals and by asking questions from
mentors.

Name: ___________________________

CLPNA Registration #: ____________

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity (include

course, seminar, research,
hours, details)

2015 Spring

Health Assessment 1000

term

Lab 30 hours

Summary of Lea

In this course I learned

practised procedures b

on theory for obtaining

history and conducting

physical examination o
adult. Examined

assessment findings fo
structures and function

of the human body. In

applied my knoeledge

based on assessment
practised by taking

health history and dem

physical assessment
skills.
2015 Spring term

NFDN 1002( CIA Lab; 24 hours),

In this course, I have le

30 hour practice) and Practicum)

practice the procedure

the lab and to applied t

learned the

administration of medi
also the importance

of checking all the ten

the safety of the

patient) before each m

In addition, I learned

how to be responsible

everything I do with my

because a small mista

effect someone's life.

Apart from that, I got ch

practice most of the

procedures which I nee

this course. For

example: medication
administration. wound

wound packing insertio

and discontinue IVs,

and teaching and disc

clients.And how to do

proper documentatio

NFDN-2003-Nursing Foundations III.

2015 Fall Term

135 hr.
45 hr. Theory
90 hr. In lab

In this course, I have le

nursing foundation of

how to provide nursing

medical/surgical

patient including woun

complex dressing and

irrigation, wound packin

and insertion of

catheters, importance o
field, inserting IV

canulas, nasogastic tub

oxygenation, and disch
planning, health
teaching.
Name: _____________________

CLPNA Registration #:__________