1.

Does Not Meet Expected Results Performance in the job function does not meet the expected performance standards and is unsatisfactory. 2. Does Not Meet All Expectations This rating reflects marginal performance - the lowest level of acceptable performance. This rating connotes that for the function the employee needs more than the expected amount of guidance and supervision. An action plan is required in section 3 stating what the supervisor expects from the employee to remedy the low rating. upervisor should include in such a plan what additional guidance and supervision will be received by the employee for improving performance in this function. 3. Meets All Expectations This rating shows that the employee meets all the expected requirements of the function and requires only the normal amount of supervision. This should be the normal of expected performance and! therefore! it can be anticipated that the majority of the wor"force will fall into this category on many job functions. 4. Exceeds Expectations This rating shows that the employee#s performance on the job function is beyond the expected level but falls short of the $maximum performers.$ The employee always meets performance requirements% often exceeds requirements and requires less than the normal amount of guidance and supervision. 5. Exceeds All Expectations This designation is only for the employee who achieves maximum performance on the job function. &is'her performance is (excellent) * the best that can be attained on this job function. The employee+s performance and achievements consistently and significantly exceed requirements and expectation for the function. The person requires little! if any! supervision and guidance. This rating is truly for the few exceptional individuals who deserve it. Provided for explanation when performance ratings of , or - are given on any function. .xplanation should include actions required by employee to improve in deficient areas. .xamples of exceptional wor" performance should also be noted if a rating of - has been given. Attach additional pages if more space is needed. Part Ill. Personal Relations .valuator should note employee#s observed level of relationship with fellow employees. .valuator should add comments! examples /incidents0 supporting the category chec"ed. 1omments should include suggestions for improvement if necessary. .valuator should note employee#s observed level of relationship /treatment of0 with customers. .valuator should add comments or examples /incidents0 supporting the category chec"ed. 1omments should include suggestions for improvement if necessary. .valuator should chec" those categories that apply to employee. Part IV. Su ar! o" E#aluation .valuator should chec" only one recommendation for each of the three categories in this section. The first two items are overall summary statements about the evaluation. The last category is a recommendation for personnel action and appropriate action should be initiated based on the recommendation made. Part V. Su$$estions "or E plo!ee De#elop ent This section is provided for the evaluator and employee to ma"e any suggestions for development activities that will enhance employee#s s"ills and abilities to perform the job in a more efficient manner. Part VI. Si$natures elf-explanatory. ignature of employee highly encouraged. 2f employee refuses to sign! then the supervisor should so note in the following manner and date3 $.mployee reviewed completed evaluation this date! but has elected not to sign form.$

Part I. %ASI& IN'(RMA)I(N N'(RMA)I(N*

4ame3 A5.3 .63 721 83

'unction Part II.
DEPAR)MEN)A+ RESP(NSI%I+I)IES

+o, 1

-i$. 5

PER'(RMAN&E RA)IN/ %0 1(% '2N&)I(N*

,. 9. 3. Assist the &eadnurse with development and implementation of 4ursing ervice goals! objectives! to facilitate improved patient outcomes. 1ommunicates professionally and effectively with &eadnurse regarding all aspects of 4ursing practice. Assist the &eadnurse with investigation of accidents and injuries to staff'patients'visitors and communicates with appropriate entities /i.e.3 1:! 14! ;:<! 4:<! upervisor! etc.0. Prepares 2ncident =eports when appropriate. 2s self-directing and follows through with responsibilities and assignments in a timely manner. ;anages time effectively to reduce the cost of overtime. upervises and instructs subordinate nursing personnel as per &ospital structure. Actively participates in the &ospital Performance 2mprovement initiatives. Nursin$ Process 3 Patient &are Responsi4ilities <elivers (Professional 4ursing) based on "nowledge and application of the principles of biological! physical! and social science. Applies 4ursing Process in the Ambulatory 1are setting! including observation! assessment! intervention! evaluation! rehabilitation! care and counsel! or health teaching of persons that are ill! injured! infirm or experiencing a change in normal health processes. <emonstrates the "nowledge and s"ills necessary to provide care appropriate to the age of the patients served. <emonstrates "nowledge of the principles of growth and development over the life span. Accurately assess the patient! being aware of variances from the normal! and reports significant findings in a timely manner. AtiliBes patient'family interview! medical records and physical assessment including ta"ing accurate vital signs! weight and height measurements to formulate patient care plan. Assists in maintaining an environment conducive to the welfare and safety of clients. Adheres to standards of 4ursing 1are as defined in 4urse Practice Act. 1ollects or performs tests ordered by the physician and prepares necessary accompanying paperwor". Accurately records end-results of tests in patient+s chart <ocuments all nursing care and behavioral assessments accurately. =enders complete and accurate verbal reports. Administers and documents medications accurately per Physician+s order. :bserves patient for reactions to administered medications and procedures! and annotates patient chart accordingly. 4otifies physician of any significant incidents Provides education' explanation to patients in a manner they can understand regarding procedures to be performed! self-care techniques! medications! etc.!.

>. -. ?. @.

,. 9.

3.

>. -. ?. @. C. D. ,E. ,,. ,9. ,3. ,>.

&(N)IN2IN/ ED2&A)I(N

-2-

'unction
,. 9. 3. >. Attends 4ursing continuing education programs applicable to population served. Assists in identifying educational needs and opportunities for the 4ursing staff and communicates these to 4urse ;anager. Participates in ;edical .mergency preparedness drills in <epartment. Attends 4ursing service staff meetings to review issues! processes! communicate new and pertinent developments! address Performance 2mprovement initiatives. E52IPMEN) Prepares necessary equipment and instruments to assist physician with examinations! treatments! and special procedures. Properly operates and cares for equipment and instruments in accordance with established procedures for clinical specialty area. .nsures that inventory of necessary supplies and equipment is maintained. =eports non-functioning equipment to the proper person. Promotes cost containment by economical use of supplies and equipment. &(ND2&) ,. <isplays appropriate! courteous attitude and behavior / respect! support! loyalty0 towards patients! healthcare team members! through appropriate eye contact! facial expressions and tone of voice. 2ntroduces self and addresses patients and visitors appropriately /when "nown0. 3. >. -. ?. @. C. D. ,E. ,,. ,9. Always demonstrates professional attitude towards hospital staff! physicians! and'or problems in front of patients. ;aintains calm professional demeanor in stressful situations =epresents the hospital in a positive and professional manner in the community 7imits personal phone calls and side-tal" :bserves hospital rules for food and drin" at wor" station Follows hospital dress code and standards for personal hygiene% wears name plate correctly .xercises discretion and maintains confidentiality in all matters relating to the hospital! its employees and patients .xhibits stability! promptness! and dependability by providing proper notification for absences or tardiness. Adheres to hospital policy for attendance and tardiness =espects allotted time limits when ta"ing brea"s and lunch periods.

+o, 1

-i$. 5

,. 9. 3. >. -.

0es .mployee &ealth Profile 1urrentG 1P= 1ertification 1urrentG ;andatory 2nservices 1urrentG 4ursing 1ore 1ompetency Training 1urrentG 7icensure Herification in File

No

PAR) III. &2S)(MERS3PERS(NA+ RE+A)I(NS a. =elationship with fellow employees3 /0 .xcellent /0 5ood -3-

/0 Ansatisfactory .xplain3 b. =elationship with customers3 /0 .xcellent /0 5ood /0 Ansatisfactory .xplain3 1omparison to previous evaluation3 /0 2mproved /0 4o 1hange /0 4egative'<ecline

Personality /1hec" those which apply0 /0 Friendly /0 Aloof /0 .njoys wor" /0 1alm under pressure /0 4egative influence on others /0 :utgoing /0 4eat in appearance /0 <ependable /0 4ervous /0 Positive influence on others /0 1ourteous /0 Antidy /0 1onscientious /0 1omplains excessively

<esire for achievement3 /0 &igh /0 Average /0 7ow

PAR) IV. S2MMAR0 (' EVA+2A)I(N :verall evaluation3 /0 Positive /0 4eeds 2mprovement :verall comparison to previous evaluation3 /0 2mproved /0 4o 1hange /0 4egative 1ontinued .mployment3 /0 =ecommended /0 =ecommended with improvement /0 4ot recommended

-4-

PAR) V. S2//ES)I(NS '(R S)A''3RN RESIDEN)S6 DEVE+(PMEN) 78I

PAR) VI. This report is based upon my observation and'or "nowledge. 2t represents my best judgement of the employee+s performance. ignature :f .mployee3 ignature :f .valuator' &eadnurse3 ignature :f A14 1linical3

<ate3

<ate3

<ate3

-5-