Sample Form Licensed Practical Nurse 2 Performance Evaluation Appraisal Score

Name: Job Title: Department: Appraisal Date: Review Period: Appraised by: From: To: Employee ID: Hire Date: Overall Score:

/ 5.0

Key Responsibilities
Professional Equipment: A graduate of an accredited LPN program. Holds a current, valid state license. UNIT SPECIFIC: MED / SURG: Recent acute M/S experience preferred. ACUTE REHAB: Recent Acute Rehab experience preferred. FIM certification within 6 months. Physical Requirements: Demonstrates good oral and written communication skills. Demonstrates basic computer knowledge. Must be able to assist with the movement of an adult patient weighing up to 300 pounds. Must be able to stand and walk for extended periods of time. Must be able to distinguish colors. Able to care for patients with infectious diseases. Able to administer aerosol medications. Exposure Categories: None

Definition of Ratings
5.0 Outstanding (exceptional; consistently exceeds expectations) 4.0 Exceeds Expectations (consistently meets, and frequently exceeds expectations) 3.0 Competent (conforms to standards, meets expectations) 2.0 Needs Improvement (does not consistently meet expectations) 1.0 Unacceptable (significantly below standard and unsatisfactory)

Hospital Behavioral Expectations

Performance Level Competency Performance Level Comments

Score: / 5.0 (25%)

Score /5.0

5 Outstanding; 4 Exceeds Expectations; 3 Competent; 2 Needs Improvement; 1 Unacceptable.

1.1 Courtesy: A. Acknowledge a customer's presence immediately by making eye contact. Respond in a warm professional manner. When possible, personalize conversations by using names.
(7%)

B. When answering the telephone, always identify yourself and speak in a professional, friendly tone. C. Address your concerns with co-workers professionally and privately 1.2 Respect/Privacy: A. Knock or announce your arrival before entering private patient areas. B. Close curtains for patient privacy as appropriate. C. Discuss confidential or sensitive information only with appropriate parties, privately. 1.3 Communication: A. Listen carefully: do not interrupt; give people your full attention. B. Keep patients and families informed about their progress through the system. C. Acknowledge customer concerns immediately. D. Seek constructive feedback regarding his / her own practice. 1.4 Responsiveness: A. Acknowledge call lights within one minute. B. Anticipate patient needs. 1.5 Teamwork: A. Take ownership and responsibility for addressing problems. B. Cooperate with others. C. Take initiative. Measure: Based on supervisory observation.

(7%)

(7%)

(6%)

(6%)

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(7%)

(7%)

(6%)

(6%)

(7%)

(7%)

(7%)

(7%)

(6%)

Nursing Process
Performance Level Competency

Score: / 5.0 (25%) 5 Outstanding; 4 Exceeds Expectations; 3 Competent; 2 Needs Improvement; 1 Unacceptable.
Performance Level Comments Score /5.0

2.1 Diagnosis / Care Needs: The LPN analyzes the assessment data to identify care needs. A. Nursing diagnoses/care needs are derived from the assessment data. B. The LPN formulates a plan to provide appropriate care based on identified patient needs. 2.2 Implementation: The patient's nursing care is based on identified nursing diagnoses/care needs and patient care standards, and is consistent with the therapies of other disciplines. A. Nursing care is based on identified nursing diagnoses/care needs. B. Nursing care is based on standards of patient care. C. Nursing care is prioritized based on assessment of patient's immediate condition or needs. D. The patient and/or significant other(s) are involved in the patient's care as appropriate. E. The LPN collaborates with the patient's family, physician and other clinical disciplines in making decisions regarding each patient's need for nursing care. F. The LPN implements patient education and involves the patient, family and/or significant other(s) as appropriate. 2.3 Evaluation: The LPN evaluates the patient's progress towards attainment of desired outcomes. A. Evaluation of the patient's response to nursing care is evident in the ongoing assessment data.
(8%)

(8%)

(7%)

(8%)

(8%)

(8%)

(8%)

(8%)

(7%)

B. Nursing diagnoses/care needs are revised based on reassessment data. 2.4 Documentation: Documents patient care management in clear, concise manner. A. Records patient's response to hospitalization, treatments, and nursing intervention on the patient care record. B. Documents medications, treatments, and nursing intervention on appropriate chart forms. C. Completes Discharge Instruction Sheet as appropriate. Measure: Based on chart review of 6 charts.

(8%)

(7%)

(7%)

(8%)

Quality Patient Care

Performance Level Competency

Score: / 5.0 (25%) 5 Outstanding; 4 Exceeds Expectations; 3 Competent; 2 Needs Improvement; 1 Unacceptable.
Performance Level Comments Score /5.0

3.1 The LPN provides patient care according to established nursing standards and policies and procedures. 3.2 The LPN applies Standard Precautions during patient contact and when handling contaminated materials. 3.3 The LPN incorporates performance improvement recommendations for change in practice and uses the recommendations to improve the quality of nursing care.

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3.4 The LPN administers medications and IV's appropriately, following hospital policy and procedures, utilizing Five Rights of Medication Administration. The LPN consistently utilizes "two unique identifiers" with patients. The LPN uses the Pyxis appropriately. Measure: Based on supervisory observation. Consider the following items to determine the rating: Does the LPN follow the restraint policy and procedure? Does the LPN always adhere to standard precautions by washing hands and gloving appropriately? Does the LPN utilize available safety devices? i.e. needles, IV caths and securement devices. Do patients have armbands/allergy bands? Does the LPN use the Pyxis appropriately, avoiding overrides, wasting medications appropriately, using Pyxis tape as intended, etc.?

(25%)

Education
Performance Level Competency

Score: / 5.0 (15%) 5 Outstanding; 4 Exceeds Expectations; 3 Competent; 2 Needs Improvement; 1 Unacceptable.
Performance Level Comments Score /5.0

4.1 The LPN acquires and maintains current knowledge in nursing practice. Maintains NRP, PALS, BLS, ACLS and ATCN as required by units. 4.2 Attends 80% of Mandatory Licensed Staff In-Services to include Nursing Skills Festival, Safety Carnival and other educational offerings as appropriate. 4.3 Attends 80% of Unit Staff Meetings.

(25%)

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4.4 Completes 100% of yearly mandatory hospital education programs: 1 Fire Safety 2 Patient/ Personal Safety 3 Infection Control / OSHA

(25%)

4
5

External / Internal Disaster BLS

Measure: Employee Education Record. Consider the following to determine the rating: The LPN must attend 80% of both the Mandatory Licensed Staff meetings as well as 80% of Unit Staff meetings to score a "2" under this standard. If the LPN attends greater than 80% this gives him/her a chance to exceed in this standard. If 4.4 is not met, the LPN must score a "1" for the entire standard.

Age Appropriate Care

Performance Level Competency

Score: / 5.0 (10%) 5 Outstanding; 4 Exceeds Expectations; 3 Competent; 2 Needs Improvement; 1 Unacceptable.
Performance Level Comments Score /5.0

5.1 The LPN completes his/her annual competency as related to Age Appropriate Care. 5.2 Administers medications appropriately and safely for age specific variations. 5.3 Provides safety measures appropriate to age of patient. 5.4 Provides patient/family education as appropriate, applying age specific principles of learning. Measure: Based on chart review of 6 charts and observation.

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Goal Results
Objectives Title: Accomplishments

Objectives Title:

Accomplishments

Objectives Title:

Accomplishments

Next Years Goals

Goals for the upcoming year should be established by the manager and employee. SMART goals will help to focus efforts and clearly define objectives. SMART goals should be: S Specific M Measurable A Attainable R Realistic T Time-bound Objectives Title: Weight

Development Plan
Development Objectives Title:

Managers Comments

Employees Comments

I have met with my manager to discuss this evaluation. I have not met with my manager to discuss this evaluation.

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