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CCP Self Assess Tool 2008 Final 1 1 1
CCP Self Assess Tool 2008 Final 1 1 1
TABLE OF CONTENTS
nd
SELF-ASSESSMENT TOOL
The Self-Assessment Tool is used to assess your professional practice using the LPN Standards of
Practice and Competency Profile as a guide. Focus your assessment on your practice as a whole and
then those Specific Competencies which are directly related to your role and responsibilities.
RATING SCALE
Assessment.
1
Excellent
2
Competent
3
Requires
Improvement
4
Developmental
5
Not Applicable
Demonstrates
excellence in the
expectations and /
or requirements of
the competency.
Meets the
expectations and /
or requirements of
the competency.
Has identified
weakness in
areas of
knowledge, skills,
attitudes, or
clinical judgment.
Requires
education and/or
orientation to
meet the
expectations and /
or requirements of
the competency.
Not applicable to
current role and
responsibility.
A: Nursing Knowledge
A-1
A-2
A-3
A-4-4
Year
20
Year
20
Year
20
Year
20
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
A-5-9
A-6
A-7
Year
2015
1
1
Page 1
nd
Competency
Number
A-8-2
B-2-2
B-2-3
B-3
B-3-2
B-4
C-5-1
C-6-1
C-7-1
C-12
D-2
D-3
D-3-7
Year
20
Year
20
Rating(
1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
2
2
1
1
3
1
1
1
1
Year
20
C: Safety
C-1 to
C-4
Year
20
B: Nursing Process
B-1
Year
2015
1
1
1
1
Competency
Number
D-4
D-5
D-7
D-8-1
D-8-2
W-2-3
W-3
Year
20
Year
20
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
W-4-5
W-5-1
W-6
W-7
W-9
W-9-4
W-11
1
1
1
1
1
1
2
X-3-5
Year
20
W-4
X-1-5
Year
20
W: Professionalism
W-1-3
Year
2015
Year
2015
Competency
Number
X-4
X-7-1
X-7-3
X-7-4
Year
20
Year
20
Year
20
Year
20
3
4
SELF-ASSESSMENT SUMMARY
Competency
Number
Year
2015
20
20
20
Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
A1, A2,
-Nursing Practice and leadership competency
A3, A7,
A8-2, B1, -Communication and Interpersonal Skills competency
B2-2, B2- -Nursing Process competency
3, B3, B32, C1 to
C4, D4,
W1-3, W23, W-3,
W11, X4,
X7-1, X7-
20
20
20
20
20
20
Competency
Number
Rating
(1-5)
Professional Activity
(include course, seminar,
research, hours, details)
Summary of Learning
Name:
CLPNA Registration #:
Professional Activity
Summary of Learning
Name:
CLPNA Registration #: