Kingdom of Saudi Arabia

PROBATIONARY PERIOD ACTION PLAN FORM Ministry of Interior

General Administration for Medical Service
Security Forces Hospital Program - Makkah

Orientee’s
Name: ABDULMAIN M. USMAN ID No. M1624 Unit: MMU

Outline activities including supervision provided to ensure that knowledge and skills are developed to a level that is
satisfactory. Evaluation should take place no later than 14 days following development of the action plan.

Required Evaluation
Problem Action Taken
Outcome Date
Staff will be able to
Staff encourage to improve
1. Hospital policies and comply and adhere to
her knowledge with unit and 8/24/2017
procedures SFHM Policies and
hospital standard of practice
Procedures.
Initiate self-study and
Learning to improve Enter Evaluation
Enter Problem Enter Required Outcome
knowledge with hospital Date
Documentations.
Enter Evaluation
Enter Problem Enter Action Taken Enter Required Outcome
Date
Enter Evaluation
Enter Problem Enter Action Taken Enter Required Outcome
Date
Enter Evaluation
Enter Problem Enter Action Taken Enter Required Outcome
Date
Enter Evaluation
Enter Problem Enter Action Taken Enter Required Outcome
Date
Enter Evaluation
Enter Problem Enter Action Taken Enter Required Outcome
Date
Enter Evaluation
Enter Problem Enter Action Taken Enter Required Outcome
Date
Enter Evaluation
Enter Problem Enter Action Taken Enter Required Outcome
Date
Enter Evaluation
Enter Problem Enter Action Taken Enter Required Outcome
Date

Demonstrated satisfactory knowledge with adherence to the hospital policies and

procedure related to his practice; IPSG’s. As per preceptor’s feedback, A. Usman
demonstrated team work with easy adaptability to the flow of the unit. He can
Evaluation:
independently perform the task safely.

Problem Resolved:  Yes ☐ No (Refer to Associate Director of Nursing)

NAME SIGNATURE ID NO. DATE

Orientee: ABDULMAIN M. USMAN SIGNATURE
M1624 /2017
Preceptor: AISAH DATUHARON SIGNATURE
M0047 Enter a date.
CRN: GAMAR AKALAL SUGALA SIGNATURE
M1465

CODE: SFHM-NUR-FRM-083 ISSUE DATE: 30.11.2016 / ISSUE No.: 1 / REVISION No.: 0 PAGE 1 OF 2
 Kingdom of Saudi Arabia
PROBATIONARY PERIOD ACTION PLAN FORM Ministry of Interior
General Administration for Medical Service
Security Forces Hospital Program - Makkah

Head Nurse: MOHAMMAD AHMED AQEL SIGNATURE

M1489 2/6/2017

CODE: SFHM-NUR-FRM-083 ISSUE DATE: 30.11.2016 / ISSUE No.: 1 / REVISION No.: 0 PAGE 2 OF 2