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Student Name: Mitali Gor

Southwestern Oregon Community College Nursing Program


Nursing 112
Foundations of Nursing in Acute Care I

Clinical Evaluation Tool


The purpose of the weekly clinical performance evaluation tool is to provide feedback about achievement of the
course outcomes and competencies and to assist the student to meet the standards of care for nurses in Oregon as
outlined in the Nurse Practice Act.

Explanation of Rating Scale:


(S) Satisfactory = Clinical performance is safe and student adequately demonstrates application of the nursing
process/clinical judgment, required skills, and expected synthesis of learning appropriate to level in the program.
Verified by direct instructor observation.

(NI) Needs Improvement = Indicates that additional learning and attention to detail is required for a particular
item or that the overall performance for the week is at a minimum level. The instructor will write an explanation of
the rating on the comments page.

(U) Unsatisfactory = Clinical performance is unsafe and inadequately demonstrates application of the nursing
process/clinical judgment model, required skills, and expected synthesis of learning appropriate to level in the
program. The instructor will write an explanation of the rating on the comments page.

(NA) Not applicable = Particular item does not apply to the clinical performance.

(NO) Not observed = Instructor did not observe or has no knowledge of the students performance of the activity.

Students with a weekly grade of NI or U will be required to meet with their advisor and clinical instructor and
discuss a plan for change in their behavior before their next clinical experience.

Safety and legal/ethical concepts are considered critical to the profession and will be graded as NI or U if any
violation occurs.

If a student is assigned a U or NI for two weeks, the faculty will review the students clinical performance and
consider the options of either placing the student on probation or dismissing from the program.

In cases of potential failure, notification of the student by the instructor that she/he has been assigned a grade of U
or NI for one week constitutes proper warning of the grade status.

If a student is placed on probation and then receives a weekly grade of U, the faculty will review the students
performance and determine whether or not the student will be dismissed from the program.

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Nursing 112 Clinical Evaluation Tool Student Name: Mitali Gor

. Clinical Week
//Competen Make
1 2 3 4 5 6 7 8 9
cy -up
4/5/1 4/12/1 4/19/1 4/26/1 5/3/1 5/10/1 5/17/1 5/24/1 5/31/1 6/7/1
(C) Dates
6 6 6 6 6 6 6 6 6 6
Course
Attendance: P=Present, Sent h p
Outcomes n/a P n/a P P P P P
A=Absent, T=Tardy ome
(O) Facility/Unit PSU MCU PSU PSU MCU RT lab
C9/O1, O2 Applies concepts and theory s
to clinical practice in client
care and written
assignments:
S S S S S S
1. Collects data and
conducts a health
assessment on a client
with an acute condition.
2. Analyzes and interprets s
the data/assessment S S S S S S
findings.
3. Prioritizes health s
S S S S S S
problems.
4. Develops a plan of care n/a
that considers the individual,
family, age of client,
S S S S S S
developmental stage,
psycho-socio-cultural issues,
and/or learning needs.
5. Evaluates and reflects on n/a
S S S S S S
plan of care.
C1/O3 Apply ANA Code of Ethics to s
care of patients with acute S S S S S S
conditions/processes.
C5/O3 Identifies roles and functions s
of members of the health
care team involved in S S S S S S
providing care for acute
conditions/processes.
C8/O5 Uses therapeutic s
communication with patients S S S S S S
and agency staf
C4/O4 Recognizes potential legal s
and ethical issues related to
client autonomy across the S S S S S S
lifespan in at risk
populations.
C6, C7, C8/ Recognizes cultural issues s
O1 and interact with clients in S S S S S S
culturally sensitive ways
C10/O2 Uses research and evidence s
to support clinical decision S S S S S S
making
C6/O2 Utilizes resources as needed S S S S S S s
C9/O2 Demonstrate responsibility s
and accountability for
professional behavior: S S S S S S
1. Performs safely in
clinical.
C3/O 2. Prepared for clinical s
(Appropriate attire,
appropriate tools such as
S S S S S S
stethoscope, skills list,
evaluation tool, assessment
tools).

Competen Make
cy -up
(C)
1 2 3 4 5 6 7 8 9
Course
Outcomes
(O)
C9/O2 Demonstrate responsibility and s
accountability for professional
S S S S S S
behavior:
2. Performs safely in clinical.
C3/O 2. Prepared for clinical (Appropriate S S S S S S s
attire, appropriate tools such as
stethoscope, skills list, evaluation tool,
assessment tools).
C4 3. Takes initiative in making decisions s
and assuming responsibility for S S S S S S
decisions.
C3 4. Looks for opportunities for s
continued learning and self- S S S S S S
development.
C4 5. Identifies behaviors and attitudes s
S S S S S S
influencing professional behavior.
C1, C2 6. Demonstrates growth in coping s
with stressful situations in a calm and S S S S S S
dependable manner.
C1/O3 7. Maintains patient confidentiality. S S S S S S s
C3 8. Completes and submits s
S S S S S S
assignments on time.
C2 9. Organizes and manages time s
S S S S S S
efectively.
C4 10. Attends and participates at post- s
S S S S S S
conference.
Instructor Initials TYF TYF TYF TYF TYF MPP MPP DEK
Student Initials MRG MRG MRG MRG MRG MRG MRG
Clinical Student
Week Instructor Comments (Include Signature) Initials
4/5/16: n/a MRG
Canceled by clinical instructor. 4/5/1
1 3

4/12/16: Mitali- Todays clinical experience was on PSU, taking care of a patient with a THA. MRG
Your care plan was very well done. It needs a little work, but it is exactly where I would 4/12/
expect a 3rd term nursing student to be. Very well done! You successfully passed all clinical 13
2 outcomes and competencies for this clinical day, as noted above by satisfactory scores
above.
Tracy Fawns, RN, MSN.Ed

4/19/16: canceled MRG


3 4/19/
13
4/26/16: Todays clinical was on MCU, taking care of a patient with bilateral gangrenous MRG
cellulitis and sepsis. Your care was deemed safe, efective, and professional. I do see some 4/26/
need to work on your care plan: Specifically, your writing needs to improve with regard to 13
grammar, punctuation, and spelling. You also need to utilize citations within your writing.
4 Your evaluations need to reflect your outcomes; did your patient meet your outcome/goal, or
not? And, if not, what adaptations would you have made? Otherwise, you met all clinical day
outcomes and competencies, as evidenced above.
Tracy Fawns, RN, MSN.Ed

5 5/3/16: Today was on PSU taking care of a patient with acute perforated diverticulitis, with a MRG
subsequent sigmoidectomy with colostomy. You care plan is still needing a lot of work with 5/03/
regard to grammar, punctuation, and spelling. While you did make many of the corrections 16
that I had suggested, I still had to spend quite some time making comments on your final
care plan/patho paper. You evaluations were better. Clinical outcomes and competencies
were met.
Tracy Fawns, RN, MSN.Ed
5/10/16: Today was on PSU taking care of a patient with a total knee replacement. We were MRG
able to do some skill check-ofs, including CMS and placing SCDs. Your care plan improved 5/10/
with regard to spelling, grammar, and punctuations but still needs some work. Your nursing 16
6 diagnoses and outcomes were quite good. Clinical outcomes and competencies were met
today.
Tracy Fawns, RN, MSN.Ed

5/17/16: Unfortunately, student sent home today due to expired CPR card dating back to MRG
January (>30 days expired). Unable to perform duties of clinical role due to this. 5/17/
7 Tracy Fawns, RN, MSN.Ed 16

MRG
05/24/2016: Today was on MCU taking care of the an end of life palliative patient, you 5/24/
learned about important interventions for the end of life care; care plan improved, hoping my 16
8 advice to read out loud, helped you!
Michelle Pringle, RN-C, BSN

5/31/2016: Todays clinical was spent with RT. You saw a lot of things including a rapid MRG
response, and a cardiac stress test. You performed professionally and with courtesy with the 5/31/
stress test patient; well done. You passed your clinical this week. Good luck for next year, 16
9 and thank you for allowing me to help.
Michelle Pringle, RN-BC, BSN

6/7/2016: Today was spent in the lab doing a sim. Mitali did excellent research to prepare for MRG
Make the sim. She made connections between the patient symptoms and what she learned, and 6/7/1
up had researched best practices for giving Lovenox and Heparin. Something to work on is 6
leadership. Dawn Kaneen S.N.
12/08/12: sw, reviewed 3/30/15sw
5