Student Name:

Jai Lee Saldivar

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.

Nursing 221 Clinical Evaluation Tool

Student Name:

Clinical
2

Compete
ncy
(C)
Course
Outcome
s
(CO)

C9
CO 1, 2,
3

CO5, 6

Dates
Attendance: P=Present, A=Absent, T=Tardy
Facility/Unit
Applies concepts and theory to clinical practice
in client care and written assignments:
1. Conducts evidence-based health assessment
2. Collects and monitors a variety of data
3. Analyzes and interprets the data/assessment
findings in increasing complex chronic
conditions.
4. Recognizes pathophysiological changes and
symptoms
5. Regularly monitors clients level of comfort
and ability to manage symptoms and
symptom distress
6. Prioritizes health problems.
7. Develops and uses evidence-based
individualized interventions
8. Develops a plan of care that considers the
individual, family, age of client, functional
issues associated with co-morbidities,
developmental stage, psycho-socio-cultural
issues, capacity for and engagement in selfhealth care, and/or learning needs.
9. Evaluates and reflects on plan of care for
clients with chronic conditions.
Develops discharge plans in collaboration with
client, family, and other members of the health
care community.

10

1/19

1/26

2/2

2/9

2/16

2/23

3/1

3/8

P
BAH/
ED/
ADUL
T

P
BAH/
ICU/
ADUL
T

P
BAH/
FBC/
LABO
R

P
BAH/
RESO
UR
ADULT

P
BAH/
MCU/
ADUL
T

P
BAH/
FBC/
LABO
R

1/12/1
6
P
BAH/
REU/
ADULT

BAH/
MCU/
PEDS

Makeup

C8
C6, 7, 8
C5
CO5
C10
CO2
C6,
CO4
C4
C9, CO
1

Uses therapeutic communication with patients

and agency staff.
Recognize cultural issues and interact with
clients in culturally sensitive ways.
Collaborates with other members of the health
care team to provide comfort and symptom
management.
Uses research and evidence to support clinical
decision making.
Utilizes resources as needed.
Able to identify/define leadership skills for
nurse's role
Exhibits critical thinking skills when prioritizing
and delegating patient care.

N/O

N/O

S
3

Compete
ncy
(C)
Course
Outcome
s
(CO)

C9,
CO1
C3

C4
C3
C4
C1,2

Demonstrate responsibility and accountability

for professional behavior:
1. Performs safely in clinical.
2. Prepared for clinical (Appropriate attire,
appropriate tools such as stethoscope,
skills list, evaluation tool, assessment
tools).
3. Takes initiative in making decisions and
assuming responsibility for decisions.
4. Looks for opportunities for continued
learning and self-development.
5. Identifies behaviors and attitudes
influencing professional behavior.
6. Demonstrates growth in coping with
stressful situations in a calm and
dependable manner.

10

Makeup

C1
C8

7. Maintains patient confidentiality.

8. Documentation of client care is accurate
and relevant and consistent with agency
policy
9. Completes and submits assignments on
time.
10.Organizes and manages time effectively.
11.Attends and participates at postconference.

C3
C2
C4

Instructor Initials
Student Initials

JT
JLCS

JT
JLCS

JT
JLCS

JT
JLCS

JT
JLCS

JT
JLCS

JT
JLCS

JT
JLCS

JT
JLCS

Week
1

Instructor Comments (Include Date/Signature)

Jai Lee, it is a pleasure to have you in my clinical group again. Your excitement for nursing care is contagious. Your
care plan and patho are complete and pertinent to your patient. I had very few comments on them. I feel this was
a successful clinical rotation for you, and I can only encourage you to continue looking for ways to increase your
knowledge and skills.
Jenny Tausch RN MSN PCCN 1/18/16
Jai Lee, I am glad that you enjoyed your rotation through the emergency department. I feel there is great value in
seeing different types of nursing care. I received numerous compliments about you from the nursing staff. I noticed
that when you were there, you were actively looking for skills to practice and new things to learn, meeting
competency 3. Please remember to initial this form when you return it to me. Other than that, great job this week.
Jenny Tausch RN MSN PCCN 1/24/16
It sounds like ICU was a busy unit today. It is too bad about your original patient; however, this is a part of life and a
part of nursing. It is important for us to be there for them and for their family. I feel that you took initiative and begin
learning about your new assignment right away, you seemed interesting in what the nurse was saying, and you
helped care for the new patient (competency 5). This was a successful clinical rotation for you; continue looking for
ways to improve yourself as a student and future nurse.
Jenny Tausch RN MSN PCCN 2/1/16
Jai Lee, what a fabulous clinical rotation for you in the Family Birth Center. Getting to see a birth is such a wonderful
experience. Your care plan and patho paper were complete and pertinent to your patient. I did not have any

Student
Initials

JLCS

JLCS

JLCS

JLCS

comments on it for you. I noticed the homework and take ways from one of the nurses, this demonstrates
competency 3 by engaging in intentional learning.
Jenny Tausch RN MSN PCCN 2/5/16
Jai Lee, this week you were able to care for two pediatric patients on the MCU. You appeared prepared and eager to
work with them. I noticed that you were consulting the primary nurse on their plan of care, and that you were
working well with all of the staff to ensure the best possible care for these patients (competency 7). Your care plan
and patho was complete and well done, the only thing that I have to comment on it was your DAR note. Yourss was
more of a summary note. A DAR note typically focuses on one incident or action. Other than that, well done this
week.
Jenny Tausch RN MSN PCCN 2/14/16
Jai Lee, I was smiling the entire time reading your resource reflection. It sounded like you had an amazing time, I am
glad that you enjoyed it. I am also pleased that you are feeling more confident in your skills and that you were able
to observe so much this clinical rotation. Keep up the good work and continue looking for ways to improve yourself
as a student and future nurse.
Jenny Tausch RN MSN PCCN 2/22/16
Jai Lee, thank you for alerting me to the events that happened last week. I did let our SOCC liaison know and she
sent out a house wide email to remind staff of what nursing students are not allowed to do. You knew your
responsibilities as a student and were able to inform the nurse of them (competency 8). It is always good to speak
up when things do not seem correct. I apologize if it was a negative experience. For your clinical day, you were able
to care for your patients without difficulty; your care plan was complete and pertinent to your patient.
Jenny Tausch RN MSN PCCN 2/28/16
ABSENT
Jai Lee, this was a great term for you. I enjoyed watching you grow as a student. I wish you all of the best during
your practicum and throughout your nursing career.
Jenny Tausch RN MSN PCCN 3/13/16

12/12/12, updated 12/15sw

JLCS

JLCS

JLCS

JLCS
JLCS