Student Name: Mitaliben R.

Gor

Southwestern Oregon Community College Nursing Program

Nursing 221
Foundations of Nursing: Chronic Care II

Clinical Evaluation Tool

The purpose of the weekly clinical performance evaluation tool is to provide feedback about achievement of the course
outcomes and competencies and to assist the student to meet the standards of care for nurses in Oregon as outlined in
the Nurse Practice Act.

Explanation of Rating Scale:

(S) Satisfactory = Clinical performance is safe and student adequately demonstrates application of the nursing
process/clinical judgment, required skills, and expected synthesis of learning appropriate to level in the program.
Verified by direct instructor observation.

(NI) Needs Improvement = Indicates that additional learning and attention to detail is required for a particular item or
that the overall performance for the week is at a minimum level. The instructor will write an explanation of the rating on
the comments page.

(U) Unsatisfactory = Clinical performance is unsafe and inadequately demonstrates application of the nursing
process/clinical judgment model, required skills, and expected synthesis of learning appropriate to level in the program.
The instructor will write an explanation of the rating on the comments page.

(NA) Not applicable = Particular item does not apply to the clinical performance.

(NO) Not observed = Instructor did not observe or has no knowledge of the students performance of the activity.

Students with a weekly grade of NI or U will be required to meet with their advisor and clinical instructor and discuss a
plan for change in their behavior before their next clinical experience.

Safety and legal/ethical concepts are considered critical to the profession and will be graded as NI or U if any violation
occurs.

If a student is assigned a U or NI for two weeks, the faculty will review the students clinical performance and consider
the options of either placing the student on probation or dismissing from the program.

In cases of potential failure, notification of the student by the instructor that she/he has been assigned a grade of U or NI
for one week constitutes proper warning of the grade status.

If a student is placed on probation and then receives a weekly grade of U, the faculty will review the students
performance and determine whether or not the student will be dismissed from the program.
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Nursing 221 Clinical Evaluation Tool Student Name:

Midter
Compete Final
2 3 4 5 6 m 7 8 9 10 Eval
QSEN ncy Eval
Compet (C) Dates 1/10 1/17 1/24 1/31 2/7 2/1 2/14 2/21 2/28 3/7
en-cies: Course
Attendance: P=Present, A=Absent, T=Tardy P P P P P P P
(KSA) Outcomes
BAH BAH BAH BAH BAH BAH BAH
(CO) Facility/Unit MCU RES FBC REU MCU ED ICU
C9 Applies concepts and theory to clinical practice
CO 1, 2, in client care and written assignments:
S S S S S S S S
3 1. Conducts evidence-based health
assessment
2. Collects and monitors a variety of data S S S S S S S S
3. Analyzes and interprets the
data/assessment findings in increasing S S S S S S S S
complex chronic conditions.
4. Recognizes pathophysiological changes and
S S S S S S S S
symptoms
KSA: Patient Centered Care

5. Regularly monitors clients level of comfort

and ability to manage symptoms and S S S S S S S S
symptom distress
6. Prioritizes health problems. S S S S S S S S
7. Develops and uses evidence-based
S S S S S S S S
individualized interventions
8. Develops a plan of care that considers the
individual, family, age of client, functional
issues associated with co-morbidities,
S S S S S S S S
developmental stage, psycho-socio-cultural
issues, capacity for and engagement in self-
health care, and/or learning needs.
9. Evaluates and reflects on plan of care for
S S S S S S S S
clients with chronic conditions.
CO5, 6 Develops discharge plans in collaboration with
client, family, and other members of the health S S S S S S S S
care community.
C8 Uses therapeutic communication with patients
S S S S S S S S
and agency staff.
C6, 7, 8 Recognize cultural issues and interact with S S S S S S S S
clients in culturally sensitive ways.
 C5

EBP KSA: KSA: Teamwork & Collaboration

CO5

Collaborates with other members of the health

care team to provide comfort and symptom S S S S S S S S
management.

C10 Uses research and evidence to support clinical

S S S S S S S S
CO2 decision making.
ionalism Profess- KSA:

C6,
Utilizes resources as needed. S S S S S S S S
CO4
C4 Able to identify/define leadership skills for
S S S S S S S S
nurse's role
C9, CO
Exhibits critical thinking skills when prioritizing
1 S S S S S S S S
and delegating patient care.

Compete
ncy
Midter
(C) Final
Course
2 3 4 5 6 m 7 8 9 10 Eval
Eval
Outcomes
(CO)

C9, Demonstrate responsibility and

KSA: Safety, Informatics, Professionalism

CO1 accountability for professional behavior: S S S S S S S S

1. Performs safely in clinical.
C3 2. Prepared for clinical (Appropriate attire,
appropriate tools such as stethoscope,
S S S S S S S S
skills list, evaluation tool, assessment
tools).
C4 3. Takes initiative in making decisions and
S S S S S S S S
assuming responsibility for decisions.
C3 4. Looks for opportunities for continued
S S S S S S S S
learning and self-development.
C4 5. Identifies behaviors and attitudes S S S S S S S S
influencing professional behavior.
 C1,2 6. Demonstrates growth in coping with
stressful situations in a calm and S S S S S S S S
dependable manner.
C1 7. Maintains patient confidentiality. S S S S S S S S
C8 8. Documentation of client care is
accurate and relevant and consistent S S S S S S S S
with agency policy
C3 9. Completes and submits assignments on
S S S S S S S S
time.
C2 10.Organizes and manages time
S S S S S S S S
effectively.
C4 11.Attends and participates at post-
S S S S S S S S
conference.
Instructor Initials JT JT JT JT JT JT JT JT
MR MR MR MR MR MR MR
Student Initials MRG
G G G G G G G

Week Instructor Comments (Include Date/Signature) Student

Initials
Mitali, this week you cared for a debilitated lady on the Medical Care Unit. I feel that you were able to meet her needs MRG
and proved full care for her. Your care plan and patho paper were complete and pertinent to your patient. I had very 01/25/17
few comments for you this week. I noticed that during post clinical conference, you actively participated and
2 provided encouragement and support to your peers. I feel this was a good week for you, continue to look for ways to
improve yourself as a student.
Jenny Tausch RN MSN PCCN 1/11/2017
Mitali, this week you were assigned to the Resource Nurse. You were actively looking for new skills to practice and MRG
new things to observe (competency 3). This was a good learning opportunity for you. Your reflection paper was nicely 01/25/17
3 done; I did not have any comments on it for you. Nice job this week, keep up the good work.
Jenny Tausch RN MSN PCCN 1/22/2017
 Mitali this week you rotated through the Family Birth Center. Your care plan was complete and well done; I did not MRG
have any comments on it for you. I am glad that you enjoyed your time there and that you were able to see a variety 02/01/17
4 of things this week.
Jenny Tausch RN MSN PCCN 2/1/2017

5 Instructor out of town

Mitali, this week you cared for two patients in the Rapid Evaluation Unit. Your care plan was complete and well done, I MRG
had very few comments on it for you. This week you were able to practice a few skills and learn some new concepts. I 02/13/20
6 feel that you are progressing well as a nursing student. This was another successful week for you, keep up the good 17
work.
Jenny Tausch RN MSN PCCN 2/12/2017
Midte Mitali is doing well in the clinical setting. She easily develops a rapport with her patients and is able to manage her MRG
time. She does seek out learning opportunities and skills to practice. I have no concerns about her at this time. 02/01/17
rm
Eval Jenny Tausch RN MSN PCCN 2/1/2017
Mitali, this week you cared for two patients on the Medical Care Unit. You were able to meet all of their needs and MRG
provide some needed extra attention to them. I have noticed in the clinical setting, you are respectful and kind to 02/22/17
7 your patients and they respond to that. Your care plan and patho was complete and well done.
Jenny Tausch RN MSN PCCN 2/18/2017
Mitali, this week you rotated through our Emergency Department. You were able to see how emergency care differs MRG
from nursing care on the floor. Your reflection paper was complete and well done; I did not have any comments on it 02/25/17
8 for you. I feel that you are progressing well in the clinical setting.
Jenny Tausch RN MSN PCCN 2/25/2017
Mitali, this week you rotated through the Intensive Care Unit to care for a critically ill patient. You were able to MRG
practice a number of skills and get some check off completed. Your care plan was good; I had very few comments on 03/04/17
9 it for you. Nice job this week.
Jenny Tausch RN MSN PCCN 3/4/2017

10

Final
Eval

12/12/12, updated 12/16sw

5