Final Clinical Evaluation

NUR 4216L BMC SBN FALL 2015 11/9/2015

Evaluation date: 11/12/2015
Evaluator: Harding, Deb (dharding@health.usf.edu)
Evaluatee: Gerez, Anjouli Marie (agerez@health.usf.edu)

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is
proactive, self-directed, 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
The student communicates pertinent information regarding the patient's
condition/concern to health team members.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication
The student communicates effectively in written form (Nursing Process Worksheet is
organized and complete)
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication
The student communicates effectively in verbal form.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication
The student initiates, maintains, and terminates the nurse-patient relationship using
principles of therapeutic communication.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication
The student functions as an advocate for the patient/family and communicates family
needs to other members of the health care team.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication
The student examines the dynamic interactions between the patient, family, community,
and society.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication
The student initiates discussion to identify and resolve interpersonal problems that impact
care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication
The student uses interpersonal skills to enhance patient/family coping abilities.

Answer: 4
Comment:

Satisfactory: Meets Standards

Standard I--Communication
The student discusses the ethical issues and approaches the ethical dilemmas that confront
the patient/family and appropriately discusses experience with faculty/preceptor.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I--Communication
The student delegates appropriately to patient care technician, family, or other team
members.
Answer: 3
Minimal
Comment: Will do this more in semester 5.
Standard I-Knowledge
The student applies knowledge of humanities, physical and social sciences, and nursing
when providing patient care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I-Knowledge
The student applies knowledge of social, cultural, and genetic factors to the care of diverse
populations.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard I-Attitude
The student does not in anyway demonstrate disrespect or inappropriate behavior to the
patient, staff, or faculty
(Comment
Answer: 5
Outstanding: Exceeds Standards
Required)
Comment: Always professional and respectful of staff, patients, families, and peers at all
times.
Standard I-Attitude
The student is actively engaged in and seeks out opportunities for learning.
(Comment
Answer: 5
Outstanding: Exceeds Standards
Required)
Comment: Always looking for learning opportunities.
Standard II-Safety
The student does not make judgmental, discriminatory, or prejudicial statements to the

patient, staff, or faculty.

Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety
The student applies principals of universal precautions, practices specific isolation
techniques, and teaches the reasons for universal precautions.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety
The student assesses patients for fall risk and applies principles of safe patient handling.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety
The student maintains the patient's physical safety by protecting the patient from harm.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety
The student maintains medical and surgical asepsis when doing procedures requiring
sterile technique.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety
The student properly identifies techniques and teaches the reasons for universal
precautions.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety
The student validates the accuracy and appropriateness of orders for nursing/medical care
prior to initiating care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety
The student implements orders accurately and efficiently.
Answer: 4
Satisfactory: Meets Standards
Comment:

Standard II-Safety
The student is able to identify potential signs and symptoms of an emergent medical
condition and promptly reports changes in the patient's health status to preceptor and/or
clinical faculty member.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard II-Safety
The student adapts skill performance using principles of theory when necessary.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Assessment
The student identifies data from the history and physical assessment to formulate
appropriate nursing diagnoses.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Assessment
The student identifies the patient's health education needs.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Diagnosis
The student synthesizes history and assessment data as well as diagnostic results into the
development of nursing diagnoses.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Plan
The student integrates psychosocial needs into care plan, identifies appropriate resources
for the plan of care, and incorporates health education into the care plan.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Plan
The student identifies measurable, expected patient outcomes that are realistic and
individualized to the patient.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Plan
The student identifies the discharge planning process and needs of the patient upon

admission and throughout the hospitalization.

Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Plan
The student demonstrates judgement in decision-making and priority setting.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Plan
The student uses appropriate collaborative resources to personalize the nursing care the
patient receives.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation
The student demonstrates understanding of the principles underlying nursing actions
appropriate for the student at this point in the curriculum.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation
The student performs skills according to agency policy and procedure and clinical lab
guidelines.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation
The student implements the written action plan/protocol considering the priorities for each
assigned patient.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation
The student implements a teaching plan based on scientific knowledge and utilizes
resources appropriately.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation
The student incorporates evidence based research into nursing practice.
Answer: 4
Satisfactory: Meets Standards
Comment:

Standard III-Nursing Process:Intervention/Implementation

The student practices individualized and culturally competent care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Intervention/Implementation
The student initiates appropriate referrals as needed.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Evaluation
The student evaluates the patient's response/outcome to the intervention.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Evaluation
The student utilizes subjective and objective data to revise nursing actions (as appropriate
for the student at that level of the curriculum).
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Organization
The student provides organized, coordinated, and prioritized nursing care for the patients
with a range of health problems.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Organization
The student organizes time and resources effectively and efficiently.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Organization
The student gathers and organizes equipment necessary for patient care/procedures.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Organization
The student identifies and seeks appropriate resources during patient care provision.
Answer: 4
Satisfactory: Meets Standards
Comment:

Standard III-Nursing Process:Organization

The student completes the daily clinical assignment in a timely manner.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Documentation
The student appropriately develops long and short term patient oriented nursing care
goals based on patient assessment and scientific principles of nursing practice.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Documentation
The student documents problems and nursing care goals in the patient record (with cosignature).
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Documentation
The student identifies and documents nursing actions/orders initiated in implementing the
plan of care.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Documentation
The student correctly enters data into the patient record in a timely manner per agency
protocol.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Documentation
The student assures privacy of the patient record at all times.
Answer: 4
Satisfactory: Meets Standards
Comment:
Standard III-Nursing Process:Critical Thinking
The student utilizes critical thinking skills to prioritize patient needs based on the patient
assessment.
Answer: 4
Satisfactory: Meets Standards
Comment:

Comments:

Ms. Gerez mentioned early in the semester in the SWOT analysis the need for more confidence.
We discussed this and I have seen great growth in this area. You are much more comfortable in
your role as a student nurse and I have seen great growth the second half of the semester.
Comments from your preceptors: Great job and patient care, patient mobility, medication and
patient education, engaged at all times, great with patients and highly motivated. I very much
agree with their assessments. You are very motivated and dedicated to learning. Your NPWs and
PATs show your understanding of the disease process and your patients needs. You have
successfully passed your MS 2 clinical. D. Harding, MS, RN 11/12/15.

Anjouli Marie Gerez has reviewed the above evaluation on 11/13/2015 9:47:00 AM and has
provided the following comment:
Addendum from anecdotal: "Anjouli was excellent today, asked excellent questions and gave
strong responses. Strong skills for this level of nursing school.