Student Name: Nancy Lilienthal

Southwestern Oregon Community College Nursing Program

Nursing 110
Foundations of Nursing: Health Promotion

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.

pg. 2
Nursing 110 Clinical Evaluation Tool Student Name: Nancy Lilienthal

. Clinical Week
Mid-
Final
2 3 4 5 6 Term 7 8 9 10 Eval
Eval
10
10- 10- 10- 11
Compet Dates /2 11/10 11/16
ency (C)
6 13 20 /3
QSEN
7
Course
Competenc Attendance: P=Present, A=Absent,
ies
Outcom P P P P P P P
(KSA) es T=Tardy
(CO) Med
Ba Ba
Bay Bay Bay Bay icati
y y
Facility/Unit Cre Cre Cre Cre on
Cre Cre st st
st st clas
st st
s
C9 Applies concepts and theory to clinical practice
CO 1, in client care and written assignments:
1. Collects data and conducts a health
S S S S S S S
2
KSA: Patient Centered Care

assessment on a client.
2. Analyzes and interprets the
data/assessment findings.
S S S S S S S
N/ N/
3. Prioritizes health problems. N/A S S S S
A A
4. Develops a plan of care that considers the
individual, family, age of client, N/ N/
developmental stage, psycho-socio-cultural
N/A S S S S
A A
issues, and/or learning needs.
N/ N/
5. Evaluates and reflects on plan of care. N/A S S S S
A A
C 8,
Uses therapeutic communication with patients
CO 5 and agency staf
S S S S S S S

C 6,7,8 Recognizes cultural issues and interact with S S S S S S S

CO 1,4 clients in culturally sensitive ways

pg. 3
EBP KSA: KSA: Teamwork & Collaboration

C10, Uses research and evidence to support clinical N/ N/

CO2 decision making
N/A S S S S
A A
C6,
Utilizes resources as needed S S S S S S S
CO2
C9, Demonstrate responsibility and accountability
CO2 for professional behavior: S S S S S S S
1. Performs safely in clinical.
C3 2. Prepared for clinical (Appropriate attire,
appropriate tools such as stethoscope, skills S S S S S S S
list, evaluation tool, assessment tools).
Informatics, Professionalism KSA: Safety,

C4 3. Takes initiative in making decisions and

assuming responsibility for decisions.
S S S S S S S
C3 4. Looks for opportunities for continued
learning and self-development.
S S S S S S S
C4 5. Identifies behaviors and attitudes
influencing professional behavior.
S S S S S S S
C1,2 6. Demonstrates growth in coping with
stressful situations in a calm and S S S S S S S
dependable manner.
C8, 9 7. Documents accurately and thoroughly
within the health record where applicable to S S S S S S S
clinical setting
C1,
8. Maintains patient confidentiality. S S S S S S S
CO3
C3, 9. Completes and submits assignments on
time.
S S S- S- S- U S
CO8
C2 10. Organizes and manages time efectively. S S S S S S S
C4,
11. Attends and participates at post-conference. S S S S S S S
CO8
P P
Instructor Initials PW PW PW PW PW
W W
Student Initials NL NL NL NL NL NL NL
pg. 4
Key: C=Competency, CO=Course Outcome, QSEN=Quality and Safety Education for Nurses, KSA=Knowledge, Skills & Attitudes (QSEN
Competencies)

Instructor include comments that are positive, areas that need improvement or are unsatisfactory. Student
Initials
Week Reference the course outcomes listed in the syllabus, the OCNE Competencies from the Nursing
Student Handbook and/or the QSEN competencies (Date/Sign all entries)
2 Bay Crest; NL
First day in the clinical setting, great job working with your partner and providing personal care

pg. 5
 and bedmaking for the residents. Great bedside manner. Continue with the excellent care.

Pamela Wick RNC MSNEd.

Bay Crest; NL
Continued to provide personal care, blood sugar check and assessments. Continue to place your
assessments on the 2nd page of your care plan being careful to place the assessments in the
3 correct areas. You have met competencies, 3, 5, 7, 8 and 9. Be sure to get your paperwork
downloaded.

Pamela Wick RNC MSNEd.

Bay Crest; NL
Good job on your care plan, see comments to include additional assessments. Very well done
utilizing the cranial nerves with your neuro assessment. Well done in clinical you are always busy
and very helpful to the residents. Great job performing your skin, HEENT, musculoskeletal, and
4
neuro assessment on your pt. Continue the excellent work. Be sure to get your paperwork
downloaded as discussed.

Pamela Wick RNC MSN Ed.

10/27; Continuing to practice your head to toe assessments stopping at respiratory. Your care NL
plan is coming along, continue to work on your patho and assessments. Be sure to get your
5 paperwork downloaded.

Pamela Wick RNC MSN Ed.

11/3; Bay Crest; Your assessments are good, you have a nice bedside manner. Continue to NL
practice and be sure to get all of your paperwork in on time. Be sure to get your paperwork
downloaded.
6
Pamela Wick RNC MSN Ed.

Midte
rm
7 NL
11/10; See comments on paper, you are doing a good job. Your assessments need to related to
pg. 6
 the assessments unique to that area you are assessing. Im not sure whats going on related to
not being able to download your papers into e-learning but please come in ASAP to figure it out
so that all are on the computer. Even 2 minute late papers will be counted.
Pamela Wick RNC MSN Ed.
11/16; Medication class; There was no name on your paper so when I printed it out I didnt know NL
who it was from Be sure to understand how to do APA heading Your paper was good, I had
8 trouble finding the information related to the screening tools and dementia response
Pamela Wick RNC MSN Ed.

10

Final

9/1/09: rev 05062011: reviewed 9/2012 sw, rev 8/2/16 sw

pg. 7