Glendale Career College- San Diego

Clinical Performance Evaluation Record

NU119 Medical Surgical Nursing I

(Print) Student Name _____________________________________ Clinical Instructor: ________________________________________

Year: Date:
(Day/Month)
Core Professionalism - Student Outcomes:
(daily total points- 9 points possible)
 Demonstrate nonjudgmental nursing care for patients with
common health problems
 Demonstrate safe and ethical practice by participating in
patient's health care decisions including protecting patient
rights, i.e. safety, confidentiality, privacy, autonomy
 Incorporate spiritual and cultural needs into the plan of care of
the patient/family across the lifespan
 Demonstrate accountability for his or her personal practice
including self-reflection on clinical performance
 Function within the professional nurse scope of practice by
collaborating with the instructor and other healthcare team
members appropriately
 Demonstrate appropriate professional behaviors related to
attendance, punctuality, appearance, honesty & attitude, and
arrives prepared for the clinical experience
 Recognize self-limits and collaborate with instructor to adapt
clinical activities as needed
 Use basic time management, technology, and prioritization
skills to plan patient-centered care
 Participate in activities that promote professional development
(i.e. patient rounds, facility learning opportunities, pre/post
conference)
Core Competencies - Student Outcomes:
(daily total points- 9 points possible)
 Seek opportunities to collaborate with other members of the
healthcare team in providing patient-centered care
 Create and implement patient-centered plans of care using
accurate and relevant assessment data for patients with
common health problems
 Utilize therapeutic communication techniques and teaching
strategies to address patient/family knowledge and
communication deficits
 Document accurate patient data according to institutional
guidelines

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  Demonstrate effective communications toward all members of
the healthcare team, patients and families
 Demonstrate competent, safe, performance of selected nursing
interventions for patients with common health problems
 Identify environmental patient safety issues
 Apply critical thinking to abnormal patient data as it relates to
the plan of care
 Develop a schedule of nursing activities for care of patients with
common health problems
Core Knowledge - Student Outcomes:
(daily total points- 7 points possible)
 Identify legal and ethical issues for patients with common health
problems
 Utilize the patient medical record for retrieval of information to
identify patient trends
 Comply with policies and procedures of the clinical facility and
nursing program
 Document accurate patient data according to institutional
guidelines
 Participate in planning health promotion, risk reduction and
disease prevention interventions to promote positive outcomes
for patients with common health problems
 Provide patient education to patients with common health
problems
 Use basic leadership and management skills to support
organizing and prioritizing patient care
Daily Points (max 25 daily)
Student’s Initials

Midterm Midterm Final Final Grade

Points Grade % Points %
Grading instructions: Points to
 Refer to reference sheet for criteria examples Date

 1 point per outcome each day, maximum 25 points

per day if each outcome IS MET
 1 point deduction for each outcome NOT met
Pass = 75% or greater Fail = 74.9 % and below Points
Possible

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 Comments
Date
In addition to general comments and remarks about strong clinical performance, a comment is required for an unmet outcome.
Professional Values
Core Competencies
Core Knowledge

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Student Name: Course:
MID-TERM Clinical Evaluation
Strengths:

Areas To Improve:

Student Signature: _______________________________ Date: __________________

* Student signature does not indicate agreement with this evaluation, only that they have read it.

Faculty Signature: _______________________________ Date: __________________

FINAL Clinical Evaluation

Strengths:

Areas To Improve:

Student Signature: _______________________________ Date: __________________

* Student signature does not indicate agreement with this evaluation, only that they have read it.

Faculty Signature: ________________________________ Date: __________________

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