1

Baton Rouge Community College

Clinical Evaluation Tool
Nursing Fundamentals - 1106

Student:
Clinical Unit / Dates:
Instructor:

Purpose: To document the student’s progress toward achievement of the clinical competencies/outcomes for this course. The final clinical evaluation of the student must reflect
satisfactory achievement of all competencies in order to pass clinical. Failure to pass the clinical component of NURS 110 results in failure of the course.

Instructions: The faculty will complete this form each clinical week or day. All competencies will be evaluated using a rating of “Satisfactory (S)”, “Needs Improvement (NI)”,
“Unsatisfactory (UA),” or “Not Applicable (NA).” Comments/recommendations must be written for all “Unsatisfactory” ratings. The student will review each evaluation and initial
each day/week. At the end of the course, the faculty will complete the final evaluation column and the summary on the last page.

The dates of all conferences will be recorded on the last page of this form. Conferences must be held for an “Unsatisfactory” rating on any clinical competency.

COURSE 110 COMPETENCIES NEEDS IMPROVEMENT UNSATISFACTORY WEEKLY EVAL F

LEARNING SATISFACTORY (S) (NI) (U) I
OUTCOMES/ N
OBJECTIVES A
L
1st 2nd 3 rd 4th 5th
The student…

Utilize the nursing process
to develop a patient-
centered plan of care.
DATE:
1. Develops a plan of care that when Requires supervision to develop a plan Fails to develop a plan of care 1.
implemented delivers safe, quality care. of care that is safe and delivers quality that is safe and delivers quality
care. care
- assesses -requires assistance to assess -fails to assess

- diagnoses -requires assistance to diagnose -fails to diagnose

- plans -requires assistance to plan -fails to plan

- implements -requires assistance to implement -fails to implement

- evaluates -requires assistance to evaluate -fails to evaluate

2. Identifies the patient in pain. Requires assistance to identify the Fails to identify the patient in 2.
patient in pain. pain.
N1106 Fall 2016
 2

COURSE 110 COMPETENCIES NEEDS IMPROVEMENT UNSATISFACTORY WEEKLY EVAL F

LEARNING SATISFACTORY (S) (NI) (U) I
OUTCOMES/ N
OBJECTIVES A
L
1st 2nd 3 rd 4th 5th
The student…

Interpret systematically
collected information.
3. Identifies potential use of complementary
and alternative healing modalities within the
nursing plan of care.
4. collects data from all appropriate sources.
Requires assistance to identify
potential use of complementary and
alternate healing modalities within the
nursing plan of care.
Requires assistance to acquire all data
Fails to identify potential use of 3.
complementary and alternate
healing modalities within the
nursing plan of care.
Fails to collect data 4.

5. Interprets data correctly by distinguishing Requires assistance to distinguish Fails to distinguish normal from 5
normal from abnormal. normal from abnormal data. abnormal data.

6. Seeks professional assistance for patients as Fails to seek professional 6.

Demonstrate effective
communication with the
patient and the health care
team.
needed. assistance for patients as needed.
7. Communicates with patients appropriately. Requires assistance to communicate Fails to communicate with 7.
with clients appropriately. patients appropriately.
8. Communicates with faculty in a timely and Fails to communicate with faculty 8.
appropriate manner. in a timely and appropriate
manner
9. Documents patient data and care in a timely Needs assistance to document in a Fails to document in a timely and 9.
and accurate manner. timely and accurate manner accurate manner

10. Uses proper format (BRCC/DON Requires assistance to document using Fails to document using the 10.
requirements and institutional) to document the proper format proper format
patient care.
11. Maintains confidentiality in all Fails to maintain confidentiality 11.
communication regarding all things
pertinent to clinical.
12. Uses correct terminology. Requires assistance to use correct Fails to use correct terminology. 12.
terminology.

Perform safe caring
nursing interventions
13. Interacts appropriately with patient, family, Requires direction to interact Fails to interact appropriately 13.
and healthcare team. appropriately with the patient, family, with the patient, family, and
and healthcare team healthcare team
14. Implements aseptic practices. Needs assistance to implement aseptic Fails to implement aseptic 14.
practices. techniques.

N1106 Fall 2016

 3

COURSE 110 COMPETENCIES NEEDS IMPROVEMENT UNSATISFACTORY WEEKLY EVAL F

LEARNING SATISFACTORY (S) (NI) (U) I
OUTCOMES/ N
OBJECTIVES A
L
1st 2nd 3 rd 4th 5th
The student…
15. Utilizes principles of caring when Needs assistance to utilize principles Fails to utilize principles of 15.
implementing nursing interventions. of caring when implementing nursing caring when implementing
interventions. nursing interventions.
16. Uses proper technique to assess vital signs. Needs assistance in properly assessing Fails to use proper technique to 16.
vital signs. assess vital signs.

17. Demonstrates correct techniques of head- Needs assistance in carrying out a Fails to correctly implement a 17.
to-toe assessment. head-to-toe assessment correctly. head-to-toe assessment.

18. Demonstrates appropriate technique in Needs assistance to correctly lift and Fails to correctly lift and move 18.
lifting and moving patients. move patients. patients.

19. Uses appropriate technique in the insertion
and care of a urinary catheter.
20. Provides proper hygienic care to clients.
Needs assistance to appropriately Fails to appropriately insert and 19.
insert and care for a patient with a care for a patient with a urinary
urinary catheter. catheter.
Requires assistance to provide Fails to provide appropriate 20.
appropriate patient hygienic care hygienic care

21. Implements appropriate skin and wound Requires assistance to implement Fails to implement appropriate 21.
care. appropriate skin and wound care skin and wound care

22. Performs applicable components of pre-op Needs assistance to implement Fails to appropriately perform 22.
and post-op care. components of pre-op and post-op pre-op or post-op care.
care.
23. Completes nursing care associated with Needs assistance to complete nursing Fails to complete nursing care r/t 23.
nursing diagnoses related to nutritional care r/t to nutritional problems. to nutritional problems.
problems.
24. Implements measures to improve patient Requires assistance to implement Fails to implement measures to 24.
oxygenation. measures to improve patient improve patient oxygenation.
oxygenation.
25. Performs selected skills safely following Requires assistance to perform Fails to perform selected skills 25.
instruction and student demonstration. selected skills safely. safely.

26. Maintains and discontinues IV fluids Requires assistance to maintain or Fails to maintain or discontinue 26.
appropriately. discontinue IV fluids. IV fluids appropriately.

27. Verbalizes knowledge of specific drugs, Fails to verbalize knowledge of 27.

their use, and potential harmful effects. specific drugs.

N1106 Fall 2016

 4

COURSE 110 COMPETENCIES NEEDS IMPROVEMENT UNSATISFACTORY WEEKLY EVAL F

LEARNING SATISFACTORY (S) (NI) (U) I
OUTCOMES/ N
OBJECTIVES A
L
1st 2nd 3 rd 4th 5th
The student…
28. Uses appropriate technique in administering Needs assistance in using appropriate Fails to use appropriate technique 28.
specific drugs via oral sublingual, rectal, technique to administer specific drugs to administer specific drugs via
topical, intradermal, subcutaneous, and via oral, sublingual, rectal, topical, oral, sublingual, rectal, topical,
intramuscular routes. intradermal, subcutaneous, and intradermal, subcutaneous, and
intramuscular routes intramuscular routes
29. Accurately calculates drug dosages. Needs assistance to accurately Fails to accurately calculate drug 29.
calculate drug dosages dosages

Participates in Simulation
Activities
Explain the relationship of
professional behavior and
the delivery of safe quality
care.
30 Performs selected skills using simulation. Did not Perform selected skills 30
using simulation
31. Prepares for clinical assignments using Fails to prepare for clinical 31.
established guidelines. assignment
32. Submits written work that is neat, Fails to submit written work that 32.
complete, and on time. is neat, complete, and on time.

33. Admits mistakes immediately and reports
to primary RN and faculty and accepts
responsibility for own actions.
34. Is aware of own limitations and seeks
guidance from primary RN or faculty as
appropriate.
35. Demonstrates cultural awareness in the
delivery of nursing care.
36. Protects patient’s rights and
confidentiality.
Requires supervision to become aware
of own limitations and to seek
guidance from primary RN or faculty
as appropriate.
Fails to admit mistakes 33.
immediately and report to
primary RN and faculty.; fails to
accept responsibility for own
actions
Fails to be aware of own 34.
limitations and to seek guidance
from primary RN or faculty as
appropriate.
Fails to demonstrate cultural 35.
awareness in the delivery of
nursing care.
Fails to protect patient’s rights 36.
and confidentiality.

37. Is consistently on time for clinical. Fails to be punctual in reporting 37.

to clinical.

38. Complies with policies and procedures of Fails to comply with policies and 38.
the ASN program and facility. procedures of the DON program
and facility.
N1106 Fall 2016
 5

COURSE 110 COMPETENCIES NEEDS IMPROVEMENT UNSATISFACTORY WEEKLY EVAL F

LEARNING SATISFACTORY (S) (NI) (U) I
OUTCOMES/ N
OBJECTIVES A
L
1st 2nd 3 rd 4th 5th
The student…
39. Demonstrates professional behavior at all Fails to act professionally at all 39.
times. times.

40. Demonstrates caring behaviors. Fails to demonstrate caring 40.

behaviors.

41. Differientiates high quality from poor Needs assistance in differientiating Fails to differentiate high quality 41.
quality care. high quality and poor quality car. from poor quality care.
Identify patient-centered 42. Identifies the patient’s needs for Needs assistance in identifying the Fails to identify the patient’s 42.
teaching/learning needs. teaching/learning interventions. patient’s need for teaching/learning needs for teaching/learning
interventions. interventions.

STUDENT INITIALS

CONFERENCE
COMMENTS FACULTY SIGNATURE STUDENT SIGNATURE
DATE

NURSING FUNDAMENTALS -110

FINAL EVALUATION (summative): Student is unable to be evaluated for two weeks due to failure to attend clinical rotation. She was a no
call no show for clinical shift x2 weeks. Student has not satisfactorily passed the clinical portion of nursing fundamentals. Program Manager
and Course coordinator notified.
Student Name:___________________________________

N1106 Fall 2016

 6

Clinical Grade: PASS FAIL

Date: Instructor Signature:

Date: Student Signature: ___________________________
BRCC N110 clinical eval tool, removed “manage resources” as directed from 4.13.07 faculty meeting
Short version has Program objectives and core values columns deleted.
Reviewed 7.8.08, addition in red, tp; Revised 9/15_Demonstrate effective communication with the patient and the health care team. Formatting. pl

N1106 Fall 2016