CLEMSON TV i School of Nursing Precoptor Evaluation Form N6220-Gerontology Fall 2018 sient a came? Tota hous witsfedents AO Please indieate if this is a Midterm oF Final Evatuation Preceptor Name (please print): ras Naa ae phan ai or eon Te Sues _in A- & [2 _)gaerisey 9 & dhs. 029 Preveptor: Pleas i tt is oa clinical ovaluatian form for the Clemson Univeniiy student you precepting. The preceptor's input into the assessment of the student's level of achievement is an integel Component of this course, You are encouraged to discuss your assessment, suggestions, and recommendations with the student. If you have questions or need further explanation or clari tion, please contact the faculty. ease assess performance by clveling the one appropriate number using the following seal ‘“1eunsafe practice; 2= below expected level; 3= at expected level; 4= above expected level; S=oulstanding n/a not applicable or insufficient inforniation/opportunity to evaluate, “unsafe practice — immediately notify course instructor History Taking T 2 3 4 (5) wa Complete, concise, relevant, organized and accurte 1234 (5) wa Appropriate time used Physical Examinati T 2 3 45 ma Appropriate, complete (age, gender, development and cultural aspects), organized 128 4G am Anproprinte tine used 12345 @ Skilitl with procedures’ diagnosti test; List those observed: _@> yo Cedures tre Clinical Judy 123 fn Complete rlevany, rgaized 4 @ sa _Uileation of sbectiveobjective infomation 12.3 4 @ ala Sete het cae priors 1 2 3 4 @ wlan Identifies ditferentiat diagnoses 23 A) 5__nla Accurately determines final diagnoses L ‘Verbal case presentation to preceptor eG ak Syessefhisog 1 2 3 4 G wa Synopsisofphysical exam and any disgnosti testing including pertinent negatives 12.3 4G wm Conitatnatnonagnent temas Patient Management 123 4 G) tla Documents accurately and efficent in health record 123 4G we Fonlates erpeuti plan 3 4 G wa oorporates heath tea 1g ond counseling, 12.3 4G we Aatresses applicable heath promotion prevent 12 3A om sles poopie pamacologeherny [orem]Faulent Mangement (continued) 2-3 4 G mim Incorporates non-pharmacotogi sare (physical therapy, eccupationa, holistic interventions) 24 4 C8) Wa Refers or ena heath counseling and specialty cars 123 4 G) wa ___Insludes follow-up plans a Rapport with Patient /Famil 3 23 4 G) wa Elicits patient confidence and cooperation 123 4 @ who Respond ose 123 4 @ vm Rellevesancoy: amen queton 123 4G wie tnvolvespatienin heath eae panning 12.3 4G wm conuricateson patents lve 1234 GY wu _Bics ptt etigs, tudes concerns Relationship with Preceptor(s) and Staff pe 3 ZO) we Demonte postive aide 123 ‘0 Wa Contes postive to wok snvironmen/intedisitiny team Responsible, dependable, respectful — ‘Accepts and responds to constructive feedback Exhibits self-control skillful Soldirected Shows initiative wa Overall rating (Please give an overall ratin; ne al re Pp ete She will be 9 Wore oh at Peeceptor signatwrsi<] — Date! 225.15 ‘Ain, hank you nn pst as Please give tote laden to hand deliver to Ae School of Nursing office gh the Unversity Center, Ferm may alto be faxed to 8642506710, ‘Lead Faculty: Nicole J. Davis, PhD, AGPCNP-BC, GNP-BC Cell: 170-639-1501, Email: njd@clemson.edu