Final Clinical Evaluation Form--Revised 4/2016

NUR 4467.001S16 VA UD 4/26/2016

Evaluation date: 4/26/2016
Evaluator: Cashman, Kristen (kcashman@health.usf.edu)
Evaluatee: Wilczynski, Nina (nina6@health.usf.edu)

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is proactive, selfdirected, and consistently engaged in learning; needs minimal guidance; is knowledgeable; and
appropriately incorporates knowledge with skills. Student is proactive and self-directed in approach to
learning.
4-Satisfactory: Meets Standards
Exhibits average performance of nursing care for this level student. Functions with minimum guidance.
Demonstrates adequate knowledge and requires minimum assistance in applying knowledge to skills.
Recognizes learning opportunities but may require assistance in utilizing them.
3-Minimal
Exhibits minimal performance of nursing care for this level student. Functions safely with moderate
guidance. Demonstrates minimal knowledge and requires moderate assistance in applying knowledge to
skills. Requires some direction in recognizing and utilizing learning opportunities. Often focuses on the
task or own behavior, not on the patient.
2-Unsatisfactory
Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects
difficulty in the provision of nursing care. Demonstrates gaps in necessary knowledge and requires
frequent or almost constant assistance in applying knowledge to skills. Requires frequent and detailed
instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the
patient.
1-Unsafe to Practice
Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and
skills and unable to integrate these into practice. Requires constant detailed instructions regarding
learning opportunities and is often unable to utilize them. Attempts activity or behavior, yet is unable to
complete. Focuses entirely on the task or own behavior, not the patient.

Standard I--Communication

1. Communicates pertinent information regarding the patient's condition/concern to health team member
2. Communicates effectively in written form (Nursing Process Worksheet is organized and complete)
3. Communicates effectively in verbal form.
4. Initiates, maintains, and terminates the nurse-patient relationship using principles of therapeutic comm
5. Functions as an advocate for the patient/family and communicates family needs to other members of the
6. Examines the dynamic interactions between the patient, family, community, and society.
7. Initiates discussion to identify and resolve interpersonal problems that impact care.
8. Uses interpersonal skills to enhance patient/family coping abilities.
9. Discusses the ethical issues and approaches the ethical dilemmas that confront the patient/family and ap
10. Delegates appropriately to patient care technician, family, or other team members.
Answer: 5
(Comment Required)
Outstanding: Exceeds Standards
Comment: Very thorough report during rounds. You are able to articulate what is going on with the patient and
are able to critically think and understand the "big picture".
Standard I-Knowledge

1. Applies knowledge of humanities, physical and social sciences, and nursing when providing patient care
2. Applies knowledge of social, cultural, and genetic factors to the care of diverse populations.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I-Attitude
1. Consistently demonstrates professional behavior as indicated by preparedness for rounds, contributing
preceptors in communication and tone.
2. Provides clinical objectives to preceptor as determined in pre-conference.
3. Preparedness for the clinical day as indicated by timely arrival to clinical in the required dress code.
4. Focused attention during post conference to peers as well as faculty.
5. Is actively engaged in and seeks out opportunities for learning.
Answer: 5
(Comment Required)
Outstanding: Exceeds Standards
Comment: You have a positive attitude and are ready to learn. You participate in post conference activities
Standard II-Safety

1. Does not make judgmental, discriminatory, or prejudicial statements to the patient, staff, or faculty.
2. Applies principals of universal precautions, practices specific isolation techniques, and teaches the reaso
3. Assesses patients for fall risk and applies principles of safe patient handling.
4. Maintains the patient's physical safety by protecting the patient from harm.
5. Maintains medical and surgical asepsis when doing procedures requiring sterile technique.
6. Properly identifies techniques and teaches the reasons for universal precautions.
7. Validates the accuracy and appropriateness of orders for nursing/medical care prior to initiating care.
8. Implements orders accurately and efficiently.
9. Is able to identify potential signs and symptoms of an emergent medical condition and promptly reports
faculty member.
10. Adapts skill performance using principles of theory when necessary.

Answer: 4
Comment:

Satisfactory: Meets Standards

Standard III-Nursing Process: Assessment

1. Identifies data from the history and physical assessment to formulate appropriate nursing diagnoses.
2. Identifies the patient's health education needs.
Answer: 4
Satisfactory: Meets Standards
Comment: You will continue to develop pedi specific assessment skills next semester during preceptorship
Standard III-Nursing Process: Diagnosis

1. Synthesizes history and assessment data as well as diagnostic results into the development of nursing dia
Answer: 5
(Comment Required)
Outstanding: Exceeds Standards
Comment: Priority nursing diagnoses are appropriate for what is going on with your patients
Standard III-Nursing Process: Plan

1. Integrates psychosocial needs into care plan, identifies appropriate resources for the plan of care, and in
2. Identifies measurable, expected patient outcomes that are realistic and individualized to the patient.
3. Identifies the discharge planning process and needs of the patient upon admission and throughout the h
4. Demonstrates judgment in decision-making and priority setting.
5. Uses appropriate collaborative resources to personalize the nursing care the patient receives.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process: Intervention/Implementation

1. Demonstrates understanding of the principles underlying nursing actions appropriate for the student at
2. Performs skills according to agency policy and procedure and clinical lab guidelines.
3. Implements the written action plan/protocol considering the priorities for each assigned patient.
4. Standard III-Nursing Process: Intervention/Implementation
5. Implements a teaching plan based on scientific knowledge and utilizes resources appropriately.
6. Incorporates evidence based research into nursing practice.
7. Practices individualized and culturally competent care.
8. Initiates appropriate referrals as needed.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process: Evaluation

1. Evaluates the patient's response/outcome to the intervention.

2. Utilizes subjective and objective data to revise nursing actions (as appropriate for the student at that lev
Answer: 4
Satisfactory: Meets Standards

Comment:
Standard III-Nursing Process: Organization

1. Provides organized, coordinated, and prioritized nursing care for the patients with a range of health pro
2. Organizes time and resources effectively and efficiently.
3. Gathers and organizes equipment necessary for patient care/procedures.
4. Identifies and seeks appropriate resources during patient care provision.
5. Completes the daily clinical assignment in a timely manner.
Answer: 5
(Comment Required)
Outstanding: Exceeds Standards
Comment: You are very organized and plan your day as if you were the primary nurse. You will continue to de
Standard III-Nursing Process: Documentation

1. Appropriately develops long and short term patient oriented nursing care goals based on patient assessm
2. Documents problems and nursing care goals in the patient record (with co-signature).
3. Identifies and documents nursing actions/orders initiated in implementing the plan of care.
4. Correctly enters data into the patient record in a timely manner per agency protocol.
5. Assures privacy of the patient record at all times.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process: Critical Thinking
1. Utilizes critical thinking skills to prioritize patient needs based on the patient assessment.
Answer: 4
Satisfactory: Meets Standards
Comment:
Comments:
Nina, it was a pleasure getting to work with you during your pediatric clinical rotation. I am so happy that
you will be able to complete your preceptorship in pediatrics. You will continue to build your confidence
communicating with your patients/family members and other members of the health care team next
semester. Thank you for your hard work!
Nina Wilczynski has reviewed the above evaluation on 4/27/2016 11:25:00 AM and has provided
the following comment: