Student Name: Alison

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.
 2

Nursing 221 Clinical Evaluation Tool Student Name:

Midter
Final
Compete 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 PSU REU
RESO
FBC APU ICU ED
U
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.

EBP KSA: KSA: Teamwork & Collaboration

C5
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
Student Initials AJ AJ AJ AJ AJ AJ AJ AJ

Week Instructor Comments (Include Date/Signature) Student

Initials
Alison, this week you cared for a post-op patient on the Post-Surgical Unit. I noticed that you had developed a good AJ
rapport with your patient and that you appeared comfortable at the bedside. You participated in the post clinical
2 conference, and your care plan was complete. I really did not have any comments on it for you this week. 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
Alison, this week you rotated through the Rapid Evaluation Unit and cared for two patients there, one who was very AJ
involved. Your care plan and patho paper were complete and well done. When I rounded on the unit, you were actively
3 looking for skills to practice and participating as a member of the team (competency 3). This was a productive week for
you, keep up the good work.
Jenny Tausch RN MSN PCCN 1/12/2017
 Alison this week you were able to follow the resource nurse. As you noticed they are a huge asset for the floors when AJ
things get busy. Your reflection paper was complete and well done; I did not have any comments on it for you. Continue
4 the good work and continue to look for ways to improve yourself as a student.
Jenny Tausch RN MSN PCCN 2/1/2017
AJ
5 Instructor out of town

Alison, this week you were able to rotate through our Family Birth Center and help with a delivery. How exciting for you AJ
to see such a wonderful moment for that family. Your care plan and patho was complete and well done, I did not have
6 any comments on it for you. Nice job this week Alison, keep up the good work.
Jenny Tausch RN MSN PCCN 2/12/2017
Midte Alison is doing well in the clinical setting. She is able to care for two patients and will look for skills to practice. I have AJ
rm no concerns regarding her at this time.
Jenny Tausch RN MSN PCCN 2/1/2017
Eval
Alison, this week you rotated through our Acute Psychiatric Unit. You were able to observe how the nursing care differs AJ
there and how the staff tries to maintain a calming therapeutic environment for the patients. Your reflection paper we
7 complete and well done, I did not have any comments on it for you.
Jenny Tausch RN MSN PCCN 2/19/2017
Alison, this week you cared for a critically ill patient in the Intensive Care Unit. I feel that you were actively engaged in AJ
learning about care of the critical patient and you were able to practice some skills. Your care plan was complete,
8 missing some in text references in your patho, and your nursing note was not in DAR format. The college does expect
you chart in that format. Other than that, this was a good week for you.
Jenny Tausch RN MSN PCCN 2/26/2017
Alison, this week you rotated through the Emergency Department. Your reflection paper was nicely done; I did not have AJ
any comments on it for you. As you mentioned, working with case management is imperative for our community and
9 patients such as yours. I feel that you were actively seeking out learning opportunities and that you worked together
with the nurses as a part of the team.
Jenny Tausch RN MSN PCCN 3/05/2017

10

Final
Eval

12/12/12, updated 12/16sw

5